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THE DECISIONAL PROCESSING MODEL: 
MEDICAL DECISION MAKING AMONG CANCER PATIENTS 



By 
SUM PETERSEN 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT 

OF THE REQUIREMENTS FOR THE DEGREE OF 

DOCTOR OF PHILOSOPHY 

UNIVERSITY OF FLORIDA 

1997 



i~U 



QU 

97 






Copyright 1997 

by 
Suni Petersen 



To my husband, Ron Leon Straub, 

my three sons, Lee, Greg, and Kevin, and 

the women my sons brought into my life, Dianne and Cori. 



ACKNOWLEDGMENTS 

It is not possible to complete a doctoral program without the assistance, tolerance, 
and support of many people. I wish to acknowledge first my husband, Ron Straub, for his 
loving support and consistent willingness to "pick up the pieces of my life" thus affording 
me the opportunity to pursue a life-long dream. 

My major goal in returning to school was to learn to do research. One person, 
Martin Heesacker, PhD, my cochair, stands out among all others in helping me achieve this 
goal. I especially appreciate his generosity of spirit in sharing his time, knowledge, 
inspiring enthusiasm in the pursuit of good science, and, most of all, his belief in my ability 
to do good research. He will always have my deepest gratitude and respect. 

especially thank James Archer, PhD, the best pinch-hitter who, in addition to his 
consistently insightful comments throughout, generously assumed chairmanship of my 
committee late in the game. I want to thank Robert Marsh, MD, for his significant role in 
assuring the assistance I received from Shands Cancer Center. It is through Dr. Marsh and 
his colleagues that I came to understand their work as an art as well as a science. I thank 
Silvia Rafuls, PhD, for teaching me the qualitative research that has so deeply influenced 
the core of my approach that it is integrated even in the pursuit of positivistic research. I 
will consistently work towards the balance and synthesis of both approaches. 

iv 



And it is to the patients that the greatest debt is owed for without them this research 
could not exist. These patients gave of their time and energy when both were precious 
commodities in order to help others in the fight against cancer. It is with their inspiring 
courage that I will continue to pursue my research. 

I also wish to thank Robert J. Hirsch for his belief in my abilities and his role in 
awarding a grant from the Milton Goodman Foundation to conduct this study. 

Finally, I wish to thank the group of persons who constitute the most important and 
wonderful part of my life: Vicky Pearson, for her nurturing friendship and one special 
breakfast at Camacho's Cafe that led to the pursuit of my doctorate; Cathy Wolfson for 
the depth of her friendship and unabashed belief in me; and Toni Sands and Lynn 
Goldman for their warmth and shared wonder during this entire process. I thank my 
parents, Doris and Ralph Guenther, who were not afraid to dream big dreams, and who 
teusht T5S to tafc? risks 

Most of all, I thank my three sons, Lee, Greg, and Kevin, for being the essence of 
my life, providing meaning, motivation, and purpose. 



v 



TABLE OF CONTENTS 



ACKNOWLEDGMENTS iv 

LIST OF TABLES x 

ABSTRACT xi 

INTRODUCTION: THE DECISIONAL PROCESSING MODEL: MEDICAL 

DECISION MAKING AMONG CANCER PATIENTS 1 

Purpose 1 

Rationale for Integration of Theories 2 

Mindfulness 2 

Elaboration Likelihood Model 4 

Coping 9 

Why Central Route Processing May Enhance Coping 10 

Significance of Study 12 

ii} powesiis i o 

Definitions of Terms 1 9 

Organization of the Remainder of the Study 22 

REVIEW OF THE LITERATURE 23 

Integration of Mind and Body 23 

Appraisal 26 

Self-Efficacy 27 

Attributions 29 

Health Behavior Change 3 1 

Immune System Functioning 3 ] 

Physical Effects of Coping 32 

Stress and Illness 34 

The Role of Emotion 37 

Construct! vist Approaches to Perception 38 

Decision Making and Illness 44 

vi 



Some Decisional Styles May Enhance Coping 47 

Coping 49 

Cancer as a Stimulus for Coping 49 

Coping Appraisal 50 

Response to Coping: Coping Strategies 51 

Outcomes of Coping 53 

Integration of Mindfulness and Social Influence Theories 54 

Decision Making and Different Modes of Processing 56 

Evidence of Mindlessness 59 

Cognitive Commitment 62 

Cognitive Commitments Are Made .... 65 

Categories of Decision Making 68 

Necessary Conditions for Mindfulness 71 

Motivation 76 

Ability 76 

Repetition 76 

Physical cues 77 

Comprehension 77 

Comparisons and similarities 78 

Evidence of Fourth Decisional Style-Ruminating 79 

Methodologic Commentary 85 

The Decisional Processing Model 86 

Decisional Styles Follow Two Routes of Processing 87 

Four Decisional Styles 88 

Some Decisional Styles More Effective 89 

Summary 92 



Overview 94 

Population 94 

Sample and Sampling Procedures 95 

Sampling Procedures 1 00 

Research Procedures 1 1 

The Interviews 102 

Relevant Variables 104 

Types of Analyses 104 

Criterion Variables 106 

Predictor Variables 108 

Dependent Variable for Hypothesis Three: Coping 1 10 

Measures and Instruments 1 1 1 

Criterion Variables Measures 1 1 1 

Predictor Variables Measures 114 

Coping Measure 122 



Vll 



Medical Data Form 123 

Hypotheses 124 

Data Analysis 125 

Limitations 127 

Limitations in Generalizabiiity 127 

Limitations in Assessment 129 

Limitations in Analyses 130 

Theoretical Limitations 1 3 1 

RESULTS 132 

Decisional Categories 1 2 1 

Hypothesis One: Placement into Decisional Categories 133 

Decisional Category Reliability 134 

Location Effects 136 

Researcher Effects 138 

Ancillary Analyses Related to Decisional Styles 139 

Personal Characteristic Effects 139 

Medical Data Effects 141 

Hypothesis Two: Predicting the Decisional Processing Model 142 

Hypothesis Three: Relationship Between Decisional Styles and Coping 144 

Effects of Decisional Style on Coping 144 

Most Troublesome Part of Cancer 1 49 

Amount of Stress Generated 150 

Hypothesis Four through Seven: Relationship of Each Scale 

to Decisional Categories 150 

Hypothesis Four - "Need fo r Cosnition Scale i '*? 

Hypothesis Six - Padua Inventory - Rumination Subscale 154 

Hypothesis Seven - Ability to Process Questionnaire 154 

DISCUSSION 157 

Summary of Results 158 

Decisional Categories 160 

Mindless Decisional Style 160 

Active and Passive Decisional Styles 164 

Ruminating Decisional Style 167 

Age and Decisional Style 168 

Education and Decisional Style 169 

Race and Decisional Style 170 

Medical Data and Decisional Style 171 

Elaboration Likelihood Model as Predictive of Decisional Style 172 

Two Routes of Processina 172 



Vlll 



Predictive Ability of ELM 1 74 

Abi 1 ity to Process 1 74 

Motivation 175 

Cognitive Responding 1 77 

Limitations 179 

Decisional Styles and Coping 180 

Limitations 1 84 

Decisional Processing Model 1 85 

Implications of the Study 187 

Four Decisional Styles: Extension of Langer's Theory 1 88 

Using ELM to Change Decisional Styles: Extension of Theory 189 

Implications for Practice 1 89 

Methodologi cal Issues 191 

Future Research 192 

Characteristics of Decisional Styles 192 

Effects of Changing Decisional Styles 1 93 

Interaction with Others and Decisional Style 193 

Conclusion 194 

APPENDS 195 

Assessment Instruments 195 

REFERENCES 215 

BIOGRAPHICAL SKETCH 242 



IX 



LIST OF TABLES 



Table Page 

2-1 The Decisional Processing Model 91 

3- 1 Frequencies and Types of Diagnoses of Participants 96 

3-2 Construct Correlations for Need for Cognition Scale 104 

3-3 Construct Correlations for Need for Closure Scale 1 1 8 

3-4 Predictor and Criteria Variables for Hypothesis Two 1 24 

3-5 Hypothesis Three: Decisional Style and Coping 126 

4-1 Decisional Style Categories 134 

4-2 Differences in Decisional Style based on Location 137 

4-3 Researcher Coverage of Interviews 139 

4-4 Decisional Style by Education Level 140 

4-5 Effects of Age and Gender on Decisional Style 141 

4-6 Means and Standard Deviations for Medical Data 142 

4-7 Means for Five Coping Subscales for Each Decisional Style 146 

4-8 Analysis of Variance for Coping Scales 132 

4-9 Frequency within Decisional Styles for Most Troublesome Part 149 

4-10 Means and Standard Deviations on Need for Cognition Scale 1 52 

4-12 Means ana itandara Deviations on Rumination iuoscaie id4 

4-13 Means and Standard Deviations on Ability to Process Questionnaire 155 



x 



Abstract of Dissertation Presented to the Graduate School 

of the University of Florida in Partial Fulfillment of the 

Requirements for the Degree of Doctor of Philosophy 

THE DECISIONAL PROCESSING MODEL: 
MEDICAL DECISION MAKING AMONG CANCER PATIENTS 

By 

Suni Petersen 

December, 1997 

Chairperson: James Archer 
CoChairperson: Martin Heesacker 
Major Department: Counselor Education 

Many factors influencing coping, progression of disease, and survival time in 
cancer patients depend on making decisions. Yet very little is known about how patients 
,-noVe th"se cntical daemons. U?in# La^i^r's tfc<*orv evf rrv'fldfn'ne'^ 2nd p-^-h- "**a 
Cacioppo's elaboration likelihood model, this study proposed a research-supported 
decisional model and tested its viability and its relationship with coping in cancer patients. 

Results supported the model. Patients demonstrated the four categories of 
decisional styles- active, passive, mindless, and ruminating- in making key medical 
decisions. Using discriminant function analysis, these styles were predicted by the 
elaboration likelihood model's constructs, providing information for the development of 
interventions which may change decisional styles. Finally, coping was significantly related 
to decisional styles. Those patients using central route processing (active and passive 

xi 



XI 1 



decisional styles) were more effective in coping than those using peripheral route 
processing. 



CHAPTER ONE 
INTRODUCTION 
THE DECISIONAL PROCESSING MODEL: 
MEDICAL DECISION MAKING AMONG CANCER PATDZNTS 

PURPOSE 

Little is known about th e way in which people arrive at crucial decisions about 
medical treatment and coping when they are confronted with a life-threatening illness. 
Although no models have been generated that address this question, there is a substantial 
body of research that provides a framework from which to build a model. From different 
reference points Ellen Langer, Richard Petty, John Cacioppo, and other depth of 
processing theorists have researched different aspects of strikingly similar behavior. The 
purpose of this study is to provide some understanding of how people make important 
medical decisions in the face of life-threatening illness by creating a research-supported 
model and testing it's viability. 

The research supporting Petty and Cacioppo's (1981) elaboration likelihood model 
(ELM) in a context irrespective of the message delivered will be integrated with Langer's 
(1989, 1994) research on decision-making to develop a decision-making model. The 
empirical support for both theories has demonstrated closely related, if not identical, routes 
of processing information. The variables which determine these routes of processing 
information are used in this study. Langer's decisional styles are used as criterion variables. 
The constructs of the ELM which determine the routes of processing are motivation, 

1 



2 
cognitive responding, and ability to process. The variables measuring these constructs are 
Need for Cognition and Ability to Process Questionnaire, drawn from the work of Petty 
and Cacioppo (1986). The other variables measuring these constructs are Need for 
Closure Scale supported by the related research of Kruglanski and Webster (1994) and the 
Padua Inventory Rumination Subscale (Sanavio, 1988). 

This study will also include an exploration of the relationship between coping and 
styles of decision-making. 

Rationale for Integration of Theories 
Mindfulness 

In Langer's theory (1989), information is processed in one of two ways, mindfully 
or mindlessly. Langer explicated a process in which mindless decisions were made 
considerably more often on the basis of a preconceived commitment to a schema. These 
decisions are made in response to a cue thst represents a small nortion of the schemata of a 
particular domain and preempts further elaboration on an issue prior to deciding. In 
contrast, mindful deciding is a two step process. The person first steps back to reconsider 
both the problem and the solution, and seeks discriminations which render the issue novel. 
The second task of mindful deciding then, is to choose between the options generated in 
the first step of this process. 

The basic premises of the mindfulness theory are 

1) There are qualitative differences between active and passive deciding. Active 
deciding is the two step process described above and passive deciding is choosing between 
options presented. 



2) Options form discrete categories when they become psychologically different for 
the person. 

3) Deciding entails information gathering until discriminations are made and the 
concept is categorized. 

4) There is no natural end point to this process. Information gathering simply stops 
when a person reaches a cognitive commitment. 

5) There are three kinds of cognitive commitment: a) personal cognitive 
commitment to content (i.e., the totality of attributes noticed), b) societal commitment to 
content (commitment to a schema assumed from cultural norms, and c) cognitive 
commitment to process (the amount of information gathering one is "supposed" to engage 
in prior to choosing). Commitment to process is content-independent and therefore 
operates separately from societal or personal commitment. 

Personal commitment means an experience or perception is labeled as belonging to 
a certain category and immediately is attributed with all the traits of that category without 
further scrutiny. If a person does not have a preconceived category into which a new 
experience fits, that is., it is psychologically different from the alternatives, the person will 
commit to a definition of the experience based on the opinions of others. The commitment 
to process is a preconceived notion, learned in a cultural context, that informs the decision 
maker about the amount of information a person is "supposed" to obtain before making a 
choice. Thus the hypothesis testing will continue a) until a personal experience category is 
found, or b) in its absence, until a culturally informed category is found. Barring either of 



4 
these being readily available, the hypothesis testing will only continue until the decision 
making has satisfied the process commitment. 

Until a cognitive commitment is made, preferences are not stable because the 
person has not yet established differences that are psychologically distinct. Because all 
decisions result in a cognitive commitment, Langer saw the errors in judgement as being 
made in the information-gathering process. However, Langer maintained that mindless 
deciding will occur unless the following conditions exist: a) a novel situation is encountered 
in which no cognitive commitment has been previously made, b) mindless deciding is more 
effortful than mindful deciding, c) external factors do not allow completion of the 
commitment, d) significantly discrepant consequences occur that have occurred in the past, 
or e) there is insufficient involvement to see any need to respond. The "illusion of 
calculated decisions is sustained by failure to realize the power of uncertainty " (Langer, 
1994, p. 45). According to Langer. it is the desire for certaintv that leads to a premature 
cognitive commitment that is made mindlessly. 
Elaboration-Likelihood Model 

Petty and Cacioppo (1986), integrating attitude change literature, discovered the 
discordant findings were explained by the existence of two routes of processing 
information: central and peripheral. Attitude change processed centrally was enduring and 
less affected by envi ronmental cues while attitude change processed peripherally was 
transitory and heavily influenced by cues. 

The basic postulates of the elaboration-likelihood model of persuasion relevant to 
this study are as follows: 



5 

1 . People are motivated to hold correct attitudes, but they differ both individually 
and siruationally on the amount of effortful thinking they are willing to engage in to 
evaluate a message. 

2. Effortful thinking is affected by the motivation to process, the ability to process, 
and the initial attitude towards the issue. 

3. As motivation and ability to process is decreased, peripheral cues become 
important determinants of persuasion. 

4. New cognitions must be stored in long-term memory. 

5. Attitude change resulting from carefully thinking about a message is more 
enduring, predictive, and resistant to counterpersuasion than changes occurring through 
responding to peripheral cues. 

The ELM states that for people to process centrally, they must have 1) the ability to 
process, 2) cognitive responding that takes a position (discriminate between options), and 
3) motivation to think carefully about the information leading to a decision (Petty & 
Cacioppo, 1981). For a person to be motivated to process via the central route, three 
situational variables must exert influence: the personal relevance of an issue, personal 
responsibility for message evaluation, and the number of message sources. 

Langer suggests that people will make decisions mindlessly (without entertaining 
any options) particularly when presented with only one alternative unless their mindless 
deciding is interrupted or more difficult than active or passive deciding or the situation is 
sufficiently novel or consequences sufficiently discrepant with the past exist to warrant 
effortful thought. She also asserts that people will engage in more active deciding when 



6 
they feel personally responsible for the outcome (Alexander, Langer, Newman, Chandler 
& Davies, 1989; Langer & Avorn, 1982). Each of these situations fit the motivation 
criteria identified in the ELM. 

Whereas the ELM suggests that peripheral route processing will occur in states 
analogous to Langer's "mindless" condition, it does not distinguish between active and 
passive deciding. Petty and Cacioppo (1986, p. 3) define central route processing as "that 
which occurs as a result of a person's careful and thoughtful consideration of the true 
merits of the information presented in support of an advocacy." Langer describes this as 
passive deciding because the person focuses on only the options presented. Langer also 
identifies active deciding whereby the person "elaborates" on that which is presented, 
considers self-information, and generates alternatives beyond those presented. There is a 
difference here which appears to be in consonance with the elaboration likelihood model, 
although Petty and Cackropo have not made this discrimination. The difference seems to 
focus on the content of the focused thought process, either self-generated or other 
generated. Since most of the research done on the ELM was conducted from a perspective 
of persuasion, the only content studied was that which was presented. Option generation 
has not been researched within the ELM. However, it is not theoretically inconsistent to 
assume that central route processing occurs both for active and passive deciders. 

There is yet another category of decision making that, while alluded to in both the 
ELM and Langer's theories, is better explained through the research on the need to avoid 
closure. This category consists of people who ruminate, and do not adequately 
psychologically distinguish one choice from another and thereby avoid committing to any 



7 
decision. One of the criteria for central route processing is that a person must have a 

position on a topic, essentially seeing enough of a difference between options as to 

determine whether arguments support or refute that position. Langer also theorizes that, 

unless people can discover differences between the choices, the choices remain, 

psychologically, the same. Although people may feel they "ought" to be able to decide, it 

is because they cannot establish any meaningful difference for themselves that they do not 

decide. Believing there are meaningful differences, yet not being able to establish 

differences, results in rumination. 

Taken together, the research supporting the elaboration likelihood model of Petty 
and Cacioppo and the theory of mindlessness espoused by Ellen Langer, suggests four 
categories of decision makers. They are (a) active deciders (mindful), (b) passive deciders, 
(c) mindless deciders, and (d) ruminators. Qualitative differences are seen by Langer 
between mindful and mindless deciding (Langer, Chanowicz, & Blank.. 1985) and by Petty 
and Cacioppo (1986) between central and peripheral route cognitive processing. Active 
deciding is better than any of the other styles because it leads to greater self-esteem, 
enhanced perceived control (Langer and White, 1993/1994), and diminished post-decision 
regret (Langer & Williams, 1993). In addition, active deciding is more likely to lead to 
more accuracy in the fit between the choice made and the individual's needs in the current 
situation. 

Stable, intrinsic differences exist among individuals in their motivation to process 
information effortfully (Petty & Cacioppo, 1981; 1984; Cacioppo, Petty, & Morris, 1983). 
This construct has been defined as a need for cognition. Need for cognition was found to 



8 
be unrelated to intelligence (Cacioppo, Petty, & Morris, 1983; Eagly & Chaiken, 1976). 

Individuals high in need for cognition were more likely to extract information and think 

effortfully about a message than those low in need for cognition. However, these 

individual factors can be overridden by situational factors. 

If a person is to carefully evaluate information using central route processing, the 
individual must have the ability to do so. Some persons have more ability than others and 
certain situations facilitate ability more than others. Distraction, message repetition, 
recipient posture, forewarning, argument strength, relevance of message, and time to 
consider are some such factors. 

Rumination is defined as shifting between a few options without generating new 
associations and without making a commitment to any of the options. People may agree to 
an option and not be committed to it. Rumination prevents a cognitive commitment or 
cognitive responses to be made. Rumination is also differentiated from effortful thought 
by accepting that which is presented or generating only a paucity of options and by the 
inflexibility of the schema involved. The need for closure construct of Kruglanski and 
Webster (1989; 1994) is used to expound upon the idea of rumination as a decisional style. 
Need for closure is "the desire for a definite answer on some topic, any answer as opposed 
to confusion and ambiguity " (Kruglanski, 1989, p. 14). Kruglanski calls the need for 
closure a specific type of epistemic motivation. It is consonant with Langer's commitment 
to a process (perhaps, "Always keep your options open"). Those people high in need for 



9 
closure would likely use mindless deciding, those with moderate need for closure would 
engage in effortful thought, and those with high need to avoid closure would be ruminators. 

Coping 

For the basis of this study, the conceptualization of coping is taken from Lazarus 
and Folkman. Coping is defined as "the cognitive and behavioral efforts to manage 
specific external and/or internal demands appraised as taxing or exceeding the resources of 
the individual" (Folkman & Lazarus, 1988, p. 6). Rather than the traditional view of 
coping which posits an individual with certain traits, this conceptualization of coping is 
process oriented. Coping is seen as context dependent and changes as the person begins 
the adaptation to the stimulus event. Adaptation occurs through the continuing ongoing 
reappraisal process in the shifting person-environment relationship (Folkman, Lazarus, 
Dunkel-Schetter, DeLongis, & Gruen, 1986). This conceptualization of coping has as it's 
objective to manage rather than control or solve the encounter. Since cancer recovery is 
subject to so many known and unknown factors, both medical and psychological, coping 
requires management of the psychological, social, and physical impact rather than removal 
of the problem. 

The Folkman and Lazarus definition of coping also departs from the traditional 
view by collapsing the hierarchy of coping activities. Ill-timed humor, while traditionally 
rated high, can be maladaptive. Specific to research on coping with cancer, denial has 
been shown to improve coping in some studies and deter coping in other studies. Rather 
than a hierarchy of coping mechanisms, this study takes the perspective that coping can 
only be judged relative to adaptative outcomes. Considerable research has been conducted 



10 
which demonstrates certain ratios and patterns of coping are related to better outcomes (see 

Chapter Two). Therefore the complex pattern of coping and the ensuing ratios of more 

effective styles than less effective styles are equated with coping in this research. 

Why Central Route Processing May Enhance Coping 

Illness can certainly be construed as a situation with relatively uncontrollable 
outcomes. When people respond to situations having uncontrollable outcomes there is an 
intervening step of hypothesis testing occuringjust prior to the exhibition of helplessness 
(Wortman & Dintzer, 1978). Individuals seek out information when confronted with a 
new situation. Ideally, this process forestalls a commitment to a decision long enough to 
influence and modify the subjective experience of a serious diagnosis and its attributions. 
Ellen Langer suggests that people often determine and categorize these decisions on the 
basis of very little external information and a limited set of internalized cues. In a study of 
persons with hypertension, the participants were told by their physician that hypertension is 
asymptomatic, yet all of them held well-formulated hypotheses about symptoms that 
informed them of changes in blood pressure. These hypotheses, while inaccurate, 
influenced how the patients monitored blood pressure and followed treatment regimens 
(Pennebaker, 1982). 

Carefully considered appraisals are essential for the management of illness. In a 
series of studies, Leventhal (1991) identified two channels of processing information that 
co-exist and both affect and are affected by the appraisal process: the schematic memory, 
consisting of automatic, nonverbal codes of the illness, and the perceptual memory, a 
composite of the individual's reflections and judgements. For effective appraisal to occur, 



11 

the individual must negotiate the flow of information from sources in the environment and 
from self awareness of relevant internal data. To remain open to possibilities and conduct 
hypothesis testing, central route processing must be used. 

Under central route processing, a person carefully considers both the information 
from external sources and self awareness (active-deciders) while conducting the appraisal 
process. The appraisals result in the formation of new ideas that are integrated into the 
underlying schema. This mechanism establishes the enduring nature of centrally processed 
decisions. Peripheral route processing functions by directly accessing a schema without the 
necessary thoughtfulness to determine if the schema still fits. The schemata invoked by 
peripheral route processing are intellectually impoverished forms of information, seriously 
inhibiting the appraisal process necessary to healthy coping with illness. 

Taking time to conduct an in depth appraisal has been shown to affect health 
outcomes. Appraisal determines when a person seeks medical treatment (Cameron, 
Leventhal, & Leventhal, 1995). Early detection and treatment of cancer is one of the most 
significant actions toward a longer life-expectancy in a cancer diagnosis. Appraisals not 
only influence how symptoms are perceived and acted upon but can trigger a system of 
thoughts about illness which deter effective treatment and coping. In a study with cancer 
patients, the use of positive reappraisal was an indicator of long-term coping (Lazarus & 
Folkman, 1984). For example, cancer patients who have undergone surgery and believe 
the cancer was eliminated have difficulty choosing to undergo noxious chemotherapy 
treatment (Leventhal, Easterling, Coons, Luchterhand, & Love, 1986). 



12 

It is more likely that under thoughtful consideration of information a more 
informed decision could be made about such significant health decisions. In fact, crucial to 
the spirit of the law on informed consent is just such an understanding (Hodne, 1995) 

Significance of Study 

The significance of this study lies in three domains: theory, practice, and future 
research. Medical decision making literature focuses on the choices the physician makes in 
response to an illness and the physician's presentation of information to the patient. This 
body of knowledge ignores the agency of the patient. A model that attempts to explain the 
decision-making of the patient has not been created. 

Efforts need to be made to extend theory. Given the extensive research support, it 
is time to bring social influence theories to applied settings. Studies are needed to 
investigate the prevalence of each route of processing and the circumstances under which 
they naturally occur. Studies are needed to understand how change from one to the other 
occurs under different "real life" circumstances. Most of all studies are needed to focus on 
outcomes of interventions based on current research. And this can only be done by 
applying assessment strategies, such as those devised by Ellen Langer, which take 
advantage of naturally occurring events to understand the social influence theories. 

The field of pyschoneuroimmunology has advanced knowledge about the 
connections between our thoughts, feelings, behavior, and physical well-being. This 
mushrooming body of research is surprisingly devoid of studies on decision making. The 
way a person makes decisions determines when they consult a physician, the treatments 
they choose, their adherence to treatment, their ways of coping, and even their prognosis. 



13 
With the exception of a few researchers, decision-making studies have largely ignored the 

evidence that people process information along two routes. These two methods of 

processing may account for differences between people in thought patterns, appraisals, 

attributions, self-efficacy, and coping styles, all of which have been shown to have a 

powerful impact on quality of life (Leity & Haase, 1996), pain (Gil et al, 1995), health 

(Fawzy et al, 1993), progression of illness (Epping- Jordan et al, 1994), and even survival 

(Rogentine et al, 1979). 

If, as hypothesized, active or passive decisional styles spawn more effective coping 
in people with serious illness, a psycho-educational program can be developed which 
increases awareness of decisional styles and facilitates use of central route processing in 
order to increase coping effectiveness. ELM constructs have been used to change core 
attitudinal processes. Since decisional styles are also core processes, the constructs 
demonstrating effective attitude change may also be effective with chancing decisional 
styles. 

In addition, the vast body of research from both Langer and Petty and Cacioppo 
explicating factors which impact how information is processed can be used to establish 
guidelines for physician communication that encourages central route processing in ways 
that enhance coping. 

Mind and Body as Integrated System 

More and more evidence is accruing linking cognitive, affective, and social factors 
with the biochemistry of the body. More effective coping has been shown to be one of the 
determinants of increased physical ability to fight cancer. Coping is affected by perception. 



14 
Perception is socially constructed, learned behavior. One of the perceptions a person 
learns from his/her life experience is how certain decisions are made and what information 
is considered. Decision-making styles may be no different than other forms of learning 
with resultant links to biochemical events of the body. 

Results of recent research are raising questions about how supposedly separate 
human systems are bounded. Psychobiologists have been investigating the transduction of 
information between learning, memory, and the limbic-hypothalamus area of the brain, to 
understand how perception is integrated with thought and behavior (McGaugh, 1983). 
Studies of state-dependent learning, in which state-dependency is defined as including 
different states within normal biological rythyms (circadian, ultradian), have detected how 
even autonomic body functions are altered through experiential learning (Rossi & Ryan, 
1986). 

Researchers investigating state -dependent learning agree that two routes exist fo r 
encoding thoughts and experience into memory: 1 ) a specific locus of memory on a 
molecular, cellular, synaptic level (Hawkins & Kandel, 1984) and 2) most importantly to 
the translation of experience, the transmission of sensory information to the limbic system 
(amygdala and hippocampus) which transforms learning and behavior into biochemical 
events (Mishkin & Petri, 1984). Mind and body are an inextricably linked information 
system. 

The work of Hans Selye (1982) on the General Adaptation Syndrome and Lazarus 
and Folkman (1984) investigating the contrast between good stress (eustress) and bad 
stress (stress resulting from need deprivation) demonstrated that these different experiences 



15 
trigger different biochemical reactions in the body. Bandura (1985) found that as self- 
efficacy improved in people with phobias, a biochemical reaction occurred that was 
identical to the reaction of those people experiencing eustress. Taken together, these 
studies suggest that the interpretation of stress and the judgement of one's ability to handle 
the stress determine the biochemical reaction in the body. 

Interpretation is a cognitive process learned through experience and amenable to 
change. When an illness strikes, a person's experience of the illness affects his/her 
biological and psychological functioning (Stenager, Knudsen, & Jensen, 1991; Ward, 
Leventhal, & Love, 1988). Shortly after patients hear from the doctor that their diagnosis 
is cancer, they are confronted with an onslaught of decisions that they themselves must 
make about prognosis and coping. Within a short time, they are catapulted into making 
decisions about attribution and efficacy as well. People assigning meaning, attributing 
causality, and consequently coming to terms with their decision about causality, are better 
able to cope with illness (Ward et al, 1988). Additionally, only if health enhancement is 
seen as within their control will patients feel capable of challenging the illness (Strecher, 
Devellis, Becker, & Rosenstock, 1986). These decisions are highly idiosyncratic (Rolland, 
1987) and have a significant effect on survival, quality of life, and coping. 

There is extensive theoretical and research support available to develop a model of 
decision making that enhances coping with life-threatening illnesses. This model builds on 
the existing body of knowledge by integrating the depth of processing models and decision 
making models and bringing that research into the field. To date, the work of Ellen Langer 
has not been conducted in a medical setting. However, in her study on preconceived 



16 
notions of aging she hypothesized two possible explanations for the results: 1) that the state 

of the body was modified by a preconceived schema of the condition of aging, or 2) that a 

greater degree of mindfulness was required to reverse the changes that occurred 

(Alexander & Langer, 1990). In bringing the theory of decision making into the field, this 

study will attempt to deepen understanding of this process. 

One of Langer's hypotheses represents a process of assimilating existing cues 
without mindful thought; the other represents mindfully correcting a formerly held opinion 
(contrast). Priester and Petty (1996) postulated that correction based processes require 
more effortful thinking. They further stated that the processes requiring effortful thinking 
are sequentially ordered by degree, and that correction-based contrast requires more 
effortful thinking than correction-based assimilation, which, in turn, requires less thinking 
than default. They recommend this relationship be tested. By using the categories 
sussested by Langer's theories, this question c?n be addressed. 

Investigating decisional processes among cancer patients and the effects of these 
processes on coping paves the way for the development of programs which improve 
coping. A product of this investigation will be a new model created by extrapolating and 
combining the research on the elaboration likelihood model, other social influence theories, 
and the theory of mindfulness. 

Hypotheses 
It is reasonable to speculate that people engaging in active or passive decision- 
making use central route processing, and that those engaging in mindless deciding or 
rumination use peripheral route processing. It is also reasonable to speculate that central 



17 
route processing will improve coping with a serious illness because more relevant 

information is considered in the reappraisal process which is essential in making informed 

decisions. Because people can shift their modes of processing from peripheral to central, 

coping may be improved through a psychoeducational program using the ELM to increase 

the likelihood of cognitively elaborating on the directives of the physician and on 

information about new coping mechanisms. The hypotheses in this study are tested in 

order to assess the utility of the decisional processing model. 

Hypothesis One 

It is anticipated that patients will exhibit different decisional styles. Although other 
decisional styles may exist, based on the theory and empirical evidence provided by 
Langer, Petty and Cacioppo, and Kruglanski, it is anticipated that patients will exhibit one 
of the four decisional styles in making medical decisions. Hypothesis One states that a 
large proportion of participants will olace themselves into the four decisional stvles (active, 
passive, mindless, and ruminating) in making medical decisions related to a diagnosis of 
cancer. It is further hypothesized that judges will also place a large proportion of patients 
into the four categories and that there will be a high level of agreement between the judges 
and the patients regarding the placement of patients into decisional categories. 
Hypothesis Two 

The second question entertained in this study was whether constructs (cognitive 
responding, motivation, and ability to process) of the elaboration likelihood model are 
predictive of the decisional style a patient will fit. Hypothesis Two states that decisional 
style categories will be predicted by the main and interactive effects of cognitive responding 



18 
(as measured by the rumination subscale), motivation (as measured by Need for Cognition 

Scale and Need for Closure Scale), and ability to process (as measured by the Ability to 

Process Questionnaire). 

Hypothesis Three 

The third main question asked in this research was whether decisional styles are 
related to coping. Hypothesis three states participants using active decisional styles will use 
more effective coping strategies (as measured by Ways of Coping Scale - Cancer Version) 
than those using passive decisional styles. And participants using both active and passive 
decisional styles (central route processing) will use more effective coping strategies than 
those using peripheral route processing, mindless, and ruminating decisional styles. 
Hypotheses Four through Seven 

In order to test whether any of the measures used in the model can alone predict 
decisional styles the following anovas will test the relationship between each measure and 
decisional style. 

4. Participants using active deciding will demonstrate significantly higher mean 
scores on the Need for Cognition Scale than those using mindless deciding or ruminating. 

5. Participants using mindless deciding will demonstrate significantly higher mean 
scores on the Need for Closure Scale than patients using the other three styles. There will 
be no significant difference between the mean scores of those using passive deciding and 
the scores of those using active deciding. The mean scores of participants using either 
active, passive, or mindless decisional style will be higher than those of the participants 
using ruminating style.. 



i9 

6. Participants using the ruminating style will demonstrate significantly higher mean 
scores on the Padua Inventory - Rumination Subscale than those patients using active 
deciding. Mean scores of those participants using both active and passive deciding will be 
equal. The mean scores of participants using active, passive, and ruminating will be 
significantly higher than the scores of those using mindless deciding. 

7. Mean scores of participants using active deciding will be equal to the scores of 
those using passive deciding and significantly higher than the scores of those using 
ruminating. Mean scores of participants with ruminating styles will be significantly higher 
than the scores of those using mindless deciding on the Ability to Process Questionnaire. 

Definition of Terms 
For the purpose of this study, the following definitions are presented: 
Active deciding is "a process consisting of two parts: 1) creating or modifying 
ootions followed by 2) selecting from among those options" (Langer. 1994). For cancer 
patients, active deciding means that they took the initiative to seek information beyond the 
sources presented by the physician, weighed self-knowledge about their life style and 
personality, and made a choice considering all three sources of information. 

Central route processing is "a type of information processing discovered in 
research on persuasion which likely occurred as a result of a person's careful and 
thoughtful consideration of its true merits of the information presented in support of an 
advocacy" (Petty & Cacioppo, 1986, p.3) 

Cognitive responding is taking a position on a particular topic and providing a 
response. 



20 
Elaboration is to carefully think about and "relate the recommendation and 
arguments to other issue-relevant information in memory" (Petty & Cacioppo, 1986, p. 
14). 

Foreclosed commitment is making a commitment to a decision based on simple 
decisional rules without effortful thought. 

Heuristic thoughts are "those classified as relevant to the discussion yet unrelated 
to the arguments' contents" (Kruglanski, Webster, & Klem, 1993). 

Mindfulness is a state of mind that results from drawing novel distinctions, 
examining information from new perspectives, and being sensitive to context. " (Langer, 
1993, p. 44). 

Mindlessness is a state in which a premature cognitive commitment is made to a 
rigid belief resulting from the unexamined acceptance of information and without 
cof?'<i-*rat'cn of <3*ts , * r >?''T r ^'~ "c^^fctive^ nLansw icQ3' , i 

Need for closure is "the desire for a definite answer on some topic, any answer as 
opposed to confusion and ambiguity" (Kruglanski, 1989, p. 14). Kruglanski (1990) further 
discriminated between need for specific closure (need for specific answers in support a 
particular dimension, ie ego-syntonic) and need for non-specific closure. 

Need for cognition is "the statistical tendency of and intrinsic enjoyment 
individuals derive from engaging in effortful cognitive activities" (Cacioppo & Petty, 
1982). 

Option-generation is "exploring more alternatives (than presented) that suggest 
new dimensions for comparison" (Langer, 1994). 



2! 
Peripheral cues are "stimuli in the persuasion context that can affect attitudes 
without necessitating processing of the message arguments" (Petty & Cacioppo, 1986, 
p. 18). 

Passive deciding is "choosing from among previously determined options " 
(Langer, 1994). 

Peripheral route processing is "routes of processing in which simple cues rather 
than scrutiny of the central merits of the issue induce change" (Petty & Cacioppo, 1986, 
p.3). 

Premature cognitive commitment is "a rigid belief that results from the mindless 
acceptance of information as true without consideration of alternative versions of that 
information" (Langer, 1993, p.45). 

Rumination is shifting between options without generating new associations and 
without msVinit ?. commitment to snv of the ontiors 

Schemata is the organization and structure of information regarding some domain 
of knowledge; "a prototypical abstraction of the complex concept it represents triggered by 
any reasonable approximation of a schema and guiding the incoming information that 
support the original schema" (Thorndyke & Hayes-Roth, 1979). 

Systematic thoughts are "those dealing with specifically with contents of the 
arguments." (Kruglanski, Webster, & Klem, 1993). 



22 
Organization of the Remainder of the Dissertation 

This dissertation is organized into five chapters. Chapter One has introduced the 

reader to the purpose, the theoretical rationale, and the significance of this study. Chapter 

Two includes a review of the literature addressing the relevance of decision-making among 

people with life-threatening illness, it's association with coping effectively, and a deeper 

explanation of the research supporting the theoretical underpinnings of the model to be 

tested. Chapter Two also introduces the Decisional Processing Model. Chapter Three, the 

methodology section, offers a detailed account of the population sample, research design, 

hypotheses, procedures for sampling and assessment, and planned analysis of the data. 

Chapter Four is the results section of the research, including results of the main and 

ancillary hypotheses. The dissertation is concluded with Chapter Five, an in-depth 

discussion of the findings in the following areas: decisional categories, the elaboration 

likelihood mode! as predictive, and the relationshiD between decisional stvles and coning. It 

provides a description of the decisional processing model based on this study's findings. 

Chapter Five concludes with implications, methodological issues, and future research. 



CHAPTER TWO 
REVIEW OF THE LITERATURE 

The body of research reviewed in this chapter is organized into seven sections: (a) 
The integration of mind and body, (b) The social construction of perception, (c) Coping 
and medical decision-making, (d) The integration of mindfulness and social influence 
theories, (e) Evidence of a fourth decisional category, (f) Methodological commentary, and 
(g) The decisional processing model. 

In the review of the literature on psychological factors affecting physical illness a 
particular emphasis is placed on cognitive factors since decisions are cognitive m nature. 
The context of these empirical studies is subsequently placed in the framework of a 
constructivist perspective. Specific to the topic of this study, a review of coping and 

decision-making model is built upon the work of Ellen Langer, Richard Petty, John 
Cacioppo, and Arie Kruglanski. Their research is included. This examination of the 
literature will conclude with the presentation of the decisional processing model. 

The Integration of the Mind and Body 
When a person is diagnosed with cancer, he/she experiences acute stress 
emotionally, socially, and physically. The intensity of this stress is not determined by the 
condition and treatment alone. Two parallel processes occur (Leventhal, Diefenbach, & 
Leventhal, 1992), one creating the cognitive assessment of the illness, the treatment, and 



24 
the prognosis; the other creating the subjective experience. Information is monitored by 

both the objective and the emotional aspects of the experience through two types of 

memory structures: a schematic memory "of the illness and a perceptual memory "about" 

the illness. Schematic memory consists of automatic, nonverbal cues of the illness; 

perceptual memory is a composite of the individual's reflections and judgements. There 

are continuous feedback loops that inform the perceptual "memory," through which the 

individual appraises his/her responses to treatment and coping efforts. 

Psychobiologists have been investigating the transduction of information between 
learning, memory, and the limbic-hypothalamus area of the brain, to understand how 
perception is integrated with thought and behavior (McGaugh, 1983) and have found that 
different perceptions are routed through different pathways of the brain. The reticular 
formation plays an important role in transducing information by reacting to novel stimuli 
through the locus coerulus. a cluster of norepinephrme-containing neurons which stimulate 
a heightened psychobiologic state, a precondition for all forms of creatively-oriented 
psychotherapy and mind-body healing experiences. The frontal cortex with it's organizing 
and planning functions has a multitude of connections with the limbic-hypothalamus area. 
The organization and synthesis of external and internal information is essential for the 
regulation of body states and takes place when information is funneled through the limbic- 
hypothalamic system. 

One of the important mediators of mind-body communication in relationship to 
healing is body image (Acterberg, 1985; Acterberg & Lawlis, 1984). Body image is a 
composite of visual imagery and cognitive judgements organized through the transduction 



25 
of information between both hemispheres of the brain. "The right hemisphere's modes of 

information transduction are more closely associated with the limbic-hypothalamic system 

and mind-body communication" (Rossi, 1986, p. 3 1). However, the raw imagery 

production of the right hemisphere must be in good communication to be transduced to the 

left hemisphere. This means information could be the "raw uninterpreted experience" 

(Leventhal's subjective perceptual memory) or the secondary process routed throught the 

left hemisphere (Leventhal's schematic memory). 

Memory and learning depend on the flow of information from the limbic- 
hypothalamic system. Sensory stimulation also results in the release of hormones and a 
great deal of empirical evidence exists showing how learning and memory are affected by 
these hormones. McGaugh (1983) discovered that retention, for example, is influenced by 
epinephrine released from the adrenal medulla. "Hormones released by experience act to 
modulate the strength of the memory of the experience and suggest that centra! modulating 
influences on memory (in the limbic-hypothalamic system) interact with influences from 
peripheral hormones" (Rossi, 1986). Following this description, all learning becomes state- 
dependent learning. 

Research by Murry and Mishkin (1985) suggests that the cross-modal association 
of sensory-perceptual information makes possible flexible patterns of information 
transduction into psychophysiological responses. To the degree that a person is able to 
react to novel stimuli, access learning from different states, synthesize the parallel 
processes, and make the cross-modal association needed to act, that individual will be able 
to influence autonomic functioning. Increasing the pathways of both self-reflective and 



26 
externally-derived information is the way in which mind-body communication can be 
enhanced. 

Science has furthered only a few ways to enhance mind-body communication. The 
factors that have been shown in research to significantly affect the body and it's response to 
illness depend on the internal communication system described above. Making truly 
informed medical decisions may also depend on this information system. 
Appraisal 

Appraisal is an interpretation of somatic sensations (Leventhal, Deifenbach, & 
Leventhal, 1992). Two types of memory structures are involved in the appraisal process, 
one schematic and the other propositional. Schematic structures are nonverbal, 
nonpropositional codes of prior illness while propositional structures consist of abstractions 
or interpretations about the illness. Representations have five attributes which are (a) 
disease label (Bauman & Leventhal, 1985: Croyle & Sande. 1988). fb) time-line fCroyle. 
1990), (c) physical, social, and economic consequences (Bishop, 1987; Croyle & Jemmott, 
1989), (d) antecedent causes, and (e) potential for cure or control (Weinstein, 1988). This 
representation is set in motion by a novel somatic situation and determines the steps taken 
to remedy the illness or, if too much anxiety is evoked, can lead to denial of the symptoms 
(Safer, Tharps, Jackson, & Leventhal, 1979). 

The illness representation drives the appraisal process. In a study of hypertensives, 
80% of the people stated they knew hypertension was asymptomatic, yet when asked if 
they could detect when their blood pressure was high, 90% said they could (Meyer, 
Leventhal, & Gutman, 1985). 



27 
In another study, symptoms experienced in the presence of environmental stressors were 
appaised as signs of stress, whereas those experienced without the presence of a stressor 
were appraised as a sign of illness (Pennebaker, 1982). Cancer patients who have 
undergone surgery and believe the cancer was eliminated have difficulty choosing to 
undergo noxious chemotherapy treatment (Leventhal, Easterling, Coons, Luchterhand, & 
Love, 1986). 

Appraisals not only influence how symptoms are perceived and acted upon but can 
trigger a system of thoughts about the illness which deter effective treatment and coping. 
In a laboratory study with induced noxious stimuli, negative thought patterns were found to 
be related to increased reporting of pain (Gil, Phillips, Webster, Martin, Abrams, Grant, 
Clark, & Janal, 1995). In an applied study, patients receiving cognitive coping skills 
training and restructuring of negative thought patterns reported more effective pain 
management, increased functional capacity, and better coning (AJtmaier. Lehmann. 
Russell, Weinstein, & Kao, 1992; James, Thorn, & Williams, 1993). 

The initial representation of the illness, including both the non-verbal experience of 
somatic stimuli and the interpretation of that stimuli, is the process by which the integration 
of information leads to the factors that influence health. It would seem that the more 
information, both internal and external, entertained by the patient, the more likely this 
representation will guide the patient towards healthy choices. 
Self-Efficacy 

Self-efficacy is defined as a subjective appraisal of one's ability to carry out specific 
behaviors to fight the illness and cope with the distress. Self-efficacy has consistently been 



28 
identified as playing a crucial role in health (Bandura, 1977; OTeary, 1985). Only if 

health enhancement is seen as within their control will patients feel capable of challenging 
the illness (Strecher, Devellis, Becker, & Rosenstock, 1986). Bandura (1995) stated that 
self-efficacy is an integral part of three domains of self-regulation: self-monitoring, 
judgements on oneself, and self-reactions. Anticipatory thoughts of self-inefficacy increase 
stress level more than actual encounters with the threat (Bandura, 1986). Perceived 
mefficacy in controlling a psychological stressor resulted in plasma catecholinamine 
secretion (Bandura, Reese, & Adams, 1982), activation of endogenous opioid systems 
(Bandura, Cioffi, Taylor, & Brouillard, 1988), and increased release of corticosteroids and 
catecholamines (Borysenko & Borysenko, 1982), all of which have immunosuppressant 
capabilities. In a study investigating phases of efficacy acquisition rather than the 
immunosuppressant effects of inefficacy, Widenfeld, OTeary, Bandura, Brown, Levine, 
and Raska (1990) demonstrated enhanced immunocomoetence during the development of 
competencies to adapt to a stressor. These findings suggest that there is a relationship 
between self-efficacy and immune system enhancement, that self-efficacy resulting from 
acquired confidence or skills can be taught, and that the more rapid the acquisition of an 
efficacious perspective, the more the likelihood of retaining higher levels of 
immunocompetence. 

Efficacy also affects how closely a person adheres to medical regimens. Specific to 
cancer treatment, interventions to increase adherence were tested (Putnman, Finney, 
Barkley, &Bonner, 1994). Self-efficacy at pre-test did not correlate with adherence but 
self-efficacy at post-test significantly correlated with increased adherence. Another 



29 
investigation found that colorectal cancer screening among high risk men increased as self- 
efficacy increased (Myers, Ross, Jepson, & Wolf, 1994) 

Expectations about one's abilities to effectively combat and cope with the illness are 
part of the appraisal of personal helplessness (Lazarus & Folkman, 1984). Personal 
helplessness is experienced when persons feel others can accomplish what they themselves 
cannot. Wormian and Dintzer (1978) suggest that before individuals arrive at a decision of 
causality or efficacy, they go through a series of hypothesis testing, a definite decision- 
making process. 
Attributions 

Attribution of causality is a major construct when determining the etiology of an 
illness, prognosis (Peterson & Seligman, 1987), and adherence to recommended medical 
regimens (Leventhal et al, 1992). The attribution process actually begins with interpretation 
of initial symptoms. The ambiguirv of "ohvsical s^rnntorns Drior to dia-mosis mav either 
prompt or delay action. A minimally threatening framework which normalizes symptoms 
prevents the person from seeking medical treatment until the symptoms exceed the 
attributed cause (Mechanic, 1972). 

Once diagnosis occurs, even in illnesses with known causes, people tend to make 
personal attributions beyond the medical cause (Janoff-Bulman & Lang-Gunn, 1988). 
These personal attributions often involve self-blame and reflect a moral tone (i.e. "I ^ot 
breast cancer because I had premarital sex.") Behavioral self-blame attributions, as 
opposed to characterological self-blame attributions, are efforts to establish a sense of a 
coherent, predictable, and controllable world (Janoff-Bulman, 1979). However, Wortman 



30 
(1975) and Janoff-Bulman (1979) studies have shown that adjusting to a one time event 
such as an accident may be quite different than with an illness where the threat of 
recurrence continues. 

Research has generally supported that people who assign meaning, attribute 
causality, and then come to terms with their decision about causality are better able to cope 
with illness (Ward et al, 1988). However, several studies exist which refute this 
perspective. Although prior research suggests that one's own actions yield greater feelings 
of control (Langer, 1975) than reliance on a belief that another person is in control, 
Langer's studies were conducted on people who were equally competent. In medical 
situations, the trained medical staff may provide a sense of control vicariously through their 
competence. In a study with breast cancer patients (Taylor, Lichtman, & Wood, 1984), 
findings supported this notion. Either the sense of oneself being in control of the cancer or 
the sense of the medical staff being in control of the cancer were significantly and 
curvilinearly related to adjustment. 

The majority of the research on attributions of causality has explored the 
relationship with coping and adjustment. In the few studies using physical factors as the 
dependent variable, compliance, preventive health behavior change, and immune system 
functioning were investigated. Attributions of causality affect the meaning a patient places 
on the outcome. If a patient feels the disease is self-caused, making personal changes 
would result in successful control of the illness. If the disease cannot be controlled in 
accordance with the attributions assigned, it may be interpreted as personal failure. One 
study on hemodialysis patients found that attempts to control outcomes that resulted in 



31 
"failure" were those who had the poorest compliance (Witenburg, Blanchard, Suls, 

Tennen, McCoy & McGoldrick, 1983). 

Health behavior change: Perhaps the most well-researched area of attributions 
and health is health behavior change for the purpose of prevention. Undergraduates who 
were unsuccessful in health behavior changes attributed their setbacks to internal, unstable, 
and controllable causes, yet they minimized the importance of the cause (Schoeneman & 
Curry, 1990). Different health behaviors elicited different attributional styles. In another 
study, attributions changed over time as the intentions of the participant changed 
(Schoeneman, Stevens, Hollis, Cheek, & Fischer, 1988). Attributions are idiosyncratic and 
change over time and situation. 

Immune system functioning: Immune system functioning is the newest area of 
investigation in the attribution literature. The few existing studies show conflicting 
findings In determining whether a causal attribute predicts the rate of immune svstem 
decline in HIV seropositive gay men, an eighteen month follow-up study controlled for 
other health mediators such as depression and risk behavior, demonstrated a decline in 
CD4 (killer cells) in participants who assigned attribution for the negative events to aspects 
of themselves (Segerstrom, Taylor, Kemeny, & Reed, 1996). Another study on chronic 
fatigue patients found that those who assigned attributions to physical causes rather than 
psychological causes had more hospitalizations, increased reported fatigue, increased 
somatic symptoms, and were more functionally impaired, yet they had less perceived 
distress (Euba, Chalden, Deale, and Wessely, 1996). In a retrospective study on cancer 
patients who survived beyond all expectations, twice as many patients attributed their 



32 
survival (during and after treatment) to spiritual, attitudinal or behavioral changes they 

made rather than to the treatment they received (Berland, 1995). More than half of these 

patients experienced a spiritual/existential shift in their lives. 

There is little doubt that attributions are important factors in response to illness. 
Almost every study detected that a majority of people do make causal attributions to illness 
but the direction or degree of this influence is only beginning to be understood. What is 
clear from the literature on attribution of causality and medical illness is the variability 
related to outcomes, adjustment, and behavior change. 
Physical Effects of Coping 

If psychological factors, i.e. what we think and feel, could affect coping and even 
the experience of pain, could they also affect survival? Initially, studies reported mixed 
results on the predictability of cancer survival and coping based on psychological factors. 
Some studies have found no relationship between Dsycholoeical factors ?rd cancer 
progression (Cassileth, Lusk, Miller, Brown, & Miller, 1985; Jamison, Burish, & Wallston, 
1987), and have concluded that, with advanced cancer, the prognosis is dictated by the 
nature of the disease. Others (Derogatis, Abeloff, & Melisaratos, 1979; Spiegel, Bloom, 
Kraemer, & Gottheil, 1989) have identified suppression of dysphoria and cognitive- 
behavioral avoidance patterns as being associated with shorter survival. Patients who re- 
evaluated their situation and reported having made considerable adjustments in their lives 
have significantly higher one year survival rates (Rogentine, van Kammen, Fox, Docherty, 
Rosenblatt, Boyd, & Bunney, 1979). From studies such as these we can extrapolate that 
those who thought more carefully about their situations took action and lived longer. 



33 
Newly adopted thought patterns and behavior are at least partial determinants of 

enhanced emotional and physical functioning. Support group participants who were taught 
stress management and coping skills showed significantly lower levels of depressive 
symptoms, fatigue, and confusion and demonstrated higher levels of vigor than controls. 
They also had significantly more large-granular lymphocytes and natural killer cells (which 
are anti-viral and anti-tumor agents; Fawzy, Fawzy, Hyun, Elashoff, Guthrie, Fahey, & 
Morton, 1993). At the six year follow-up, survival rates were decisively enhanced 
although the difference could not be accounted for solely by the participants' improved 
immune system function. 

In another study, psychological symptoms, avoidance, and intrusive thoughts were 
used as variables to predict progression over one year (Epping- Jordan, Compas, & Howell, 
1994). General psychological symptoms were not predictive of progression. This finding 
;<• cr-^sistert with A t^er ?tndfes bv C'is"i 1o+ Vi et al. nQSi5> nry* Jarnj«n>Tt et s] 'io?" 7 ^ ?Vtf \ 
perhaps reflect generalized distress rather than features that affect cancer more directly. 
Intrusive thoughts also did not predict disease status. However, avoidance of intrusive 
thoughts and emotions was significantly predictive. Other studies have reported similar 
findings (Billings & Moos, 1981; Holahan & Moos, 1 986). When symptoms of distress 
are measured more broadly, no relationship is found; when specific symptoms (supported 
in research) are assessed, they do predict progression or survival. In AIDS patients, denial 
predicted a decline in CD4 cells (an important immunological predictor of HIV infection) 
and progression from HIV to AIDS. This pattern was not seen in those demonstrating a 



34 
"fighting spirit" which was defined as an optimistic attitude accompanied by a search for 

more information (Solano, Costa, Salvatix, Coda, Auita, Mezzaroma, & Bertini, 1993). 

Coping has previously been viewed as a quality that enhances life while an 
individual deals with an illness. It is also emerging as a causal factor in the direction of the 
illness itself. Research on the interrelated alliance between the mind and body has 
expanded considerably and previously undetected links are being revealed. 
Stress and Illness 

Stress and the ability to cope with stress have significant effects on many physical 
illnesses and there is evidence that this effect occurs through the impact of stress on the 
immune system and the mediation of coping factors (Eysenck, 1985; Fox, 1983; Korneva, 
Klimento, & Shkhinek, 1985). 

One of the well-investigated theories regarding immune system functioning and 
cancer was offered by LeShan (1959). According to LeShan, loss leads to demission 
which leads to helplessness. Cancer had initially been associated with recent prior loss. 
Another early theory was that cancer patients suppress emotion and employ an excessive 
use of denial (Bahnson & Bahnson, 1964; Kissen & Eysenck, 1962). Evidence from many 
early studies both supported and contradicted this relationship (Dattore, 1978; Dattore, 
Stontz, & Coyne, 1980). The studies supporting these theories were conducted only on 
people who had cancer. In a longitudinal study of 1350 participants drawn from the 
general population and followed over a ten year period, results demonstrated chronic 
helplessness correlated with cancer (r=.59) and anti-emtional behavior correlated (r= 51), 
(Grossarth-Maticek, Kanazir, Schmidt, & Vetter, 1982; 1985). In this series of studies, a 



35 
synergistic effect was found in lung cancer patients between smoking and the personality 
factors of chronic helplessness and anti-emotional behavior. 

There is a difference between acute stress and chronic stress in the development of 
cancer. Acute stress has immunosuppressant qualities. Acute stressors have been shown to 
affect immunity (Herbert & Cohen, 1993; Kiecolt-Glaser, Cacioppo, Malarkey, & Glaser, 
1992). In a first-time parachute jump, participants' NK cell activity increased immediately 
after the jump and within one hour, the NK cells fell to below baseline (Schedlowski, 
Jacobs, Stratmann, Richter, Hadicke, Tewes, Wagner, & Schmidt, 1993). Both NK cells 
and lymphocyte count have been shown to respond to stress and the perception of stress. 

Chronic stress in some studies has been shown to have an opposite effect (Eysenck, 
1983; 1984a; 1984b). Eysenck calls this factor the inoculation effect, which supports the 
idea that coping is a mediator to stressors. In a study by Rodin (1980; 1986), elders 
subjected to stress and exhibiting helplessness were taught new coping strategies. These 
adults not only became happier and more actively interested, but survived significantly 
longer than their cohorts without training. Cortisol levels (which display 
immunosuppressant capabilities) were also measured in this study. In the group that 
learned new coping strategies, the participants' Cortisol level decreased significantly. A one 
year follow-up indicated these levels were maintained. 

Cancer patients were provided with chemotherapy alone or chemotherapy and 
cognitive behavioral training to cope (Grossarth-Maticek, Kanazir, Vetter, and Jankovic 
(1983). Mean survival time of all patients was 15.7 months. Those receiving 
chemotherapy alone survived 2.8 months longer; those receiving coping training alone 



36 
increased their survival time 3.64 months. Patients receiving both treatments increased 

their survival time by 22.4 months. This clearly demonstrates a synergistic effect by using 
both treatments. 

It is not enough, however, to know that what we think and how we express our 
emotions affect autonomic functioning such as the immune system, lymphocyte count and 
hormone levels. It is equally important to know how the effect occurs. In his pioneering 
research, Robert Ader (1981) demonstrated the ability to train rats through behavioral 
conditioning to increase or inhibit their immune system functioning thus suggesting that 
even the autonomic system functioning can be affected by learning. 

When stress occurs, corticosteroids from the cortex of the adrenal glands raise 
blood sugar levels, reduce inflammation, and suppress immune system functioning. They 
also prompt mood changes, especially depression. The medulla of the adrenal glands 
secrete epinephrine and norepinephrine which increase heart rate and blood pressure to 
deliver blood to the large muscles in preparation for a flight or fight response. 
Norepinephrine also increases the natural killer cells, cells believed to attack cancer cells. 
These discoveries led to the question of how the transmission of the message releases 
certain hormones when certain perceptions occur. Neuropeptides flowing to and from the 
pituitary gland have been linked to the body's stress responses, the immune system, and the 
limbic system, that portion of the brain critical to drives and emotions. Furthermore, this 
interconnected message delivery system is reciprocal. 



37 
The Role of Emotions 

Research has supported the notion that cognition affects both the experience of an 
illness and in at least some cases, the progression of the illness. Studies have shown that 
there is a correlation between cognition and these factors, that changing cognition 
positively affects these factors, and that cognitive restructuring can even predict long term 
survival. 

But what about emotions? Other studies have demonstrated the effect of the lack 
of emotional expression and it's effect on the immune system and cancer. Aside from the 
expression of emotion, the linking of certain emotions with cancer has had a long history of 
exploration. The results in this body of literature are mixed. Mixed results demonstrating 
the link between depression and progression of disease have been found in the 
psychological literature. Some findings demonstrate effects of emotions on physical 
functioning (Epping- Jordan et al. 1994; Grossarth-Maticek. 1992: Herbert & Cohen. 
1993); other studies found no relationship (Buddeberg, Wolf, Sieber, Riehl-Emde, 
Bergant, Steiner, Landolt-Ritter, & Richter, 1991; Cassileth, Lusk, Miller, Brown, & 
Miller, 1985; Jamison, Burish, & Wallston, 1987). If the medical literature is consulted, 
depression is not associated with cancer (Hahn & Pettiti, 1988; Weissman, Myers, & 
Thompson, 1986). The difference lies in the methodology of these studies and the 
difference definitions of depression. The medical literature uses the standard of "clinical 
pathological depression", typically the MMPI Scale, while the psychological literature uses 
depression scales which detect depressive symptoms in fully-functioning people. Some of 
the psychological studies use broad measures of emotional distress and others use measures 



38 
of specific emotional reactions. The medical literature contains an abundance of 

epidemiological surveys while the psychological literature uses more experimental and 
quasi-experimental designs. 

Another chronic emotional state associated with illness is hostility. Hostility has 
been identified as one of the causal factors in heart disease (Dembroski, MacDougall, 
Costa, & Grandits, 1989; Hecker, Chesney, Black, & Frautschi, 1988), and related to 
general health outcomes (Adams, 1994). A link between hostility and cancer has not been 
explored. 

The role of emotion in illness goes far beyond contributing to the cause or 
inhibiting recovery. Interactive effects between emotion and cognition are powerful 
determinants of health and enjoy a long history of research. Although there is an integral 
relationship between emotion and cognitions influencing illness, reviewing the literature 
devoted to this body of knowledge is bevond the scone of this research. 

Constructivist Approaches to Perception 

Perception is the key to how events are interpreted and it is essentially social in its 
nature. Every culture has its images of illness and healing. The shaman drew on self- 
healing through images of spirits, the Chinese drew on self-healing through facilitating the 
energy flow of the body. Even Western medicine has acknowledged the power of the 
placebo effect. In an analysis of eleven published double-blind studies conducted in 
various laboratories on pain relievers, Evans (1981) found that 36% of the patients taking a 
placebo experienced at least 50% pain relief. In another study conducted on responses to a 
variety of medical problems (hypertension, cardiac pain, headaches, blood cell counts, 



39 
fever and others) Evans (1985) found a placebo effect of 55% across various medical 

procedures. The common feature among the cultural images of illnesses and the ensuing 
attempt to cure are the belief that the cure will work. 

Even though the culture provides a framework for the interpretation of illness, 
images are not only cultural but are also highly idiosyncratic (Rolland, 1987). These 
culturally-bounded, idiosyncratic beliefs determine people's attributions of causality 
(Eklund & MacDonald, 1991), self-efficacy (Bandura, 1985), prognosis (Peterson & 
Seligman, 1987), and the actions they take (Ajzen & Timko, 1986). 

How does a patient arrive at a definition of his/her disease? How does a "body of 
knowledge" about a disease become an accepted reality? The tenets of constructivistic 
approaches provide a framework from which to explore this problem. Both the social 
constructionist and the cognitive constructivists share an important perspective for this 
study. The commonality between these approaches are that reality is constructed (a 
process of mentation) and reality is heavily influenced by the social context. The 
perception of reality then, is a function of both the social context and an individual's active 
construal of events. 

Beginning with the visit to the doctor, the "problem" takes the form of a 
construction shared by the patient and the physician. Differences have been documented 
in the reporting of symptoms by patients based on different approaches from the physician, 
and by the gender, age, race, and class of the patient (Svarstad, 1976). In an early study by 
Klein (1967), spouses of the persons identified as having a serious illness often had 
significant illnesses themselves and, in some cases, more severe than the spouses but they 



40 
were never labeled as the "ill" persons in the family. Apparently the image of illness and 
the roles of the family members took precedence in defining the "reality" although these 
constructs were clearly disparate from the biology of the people involved. 

Constructionism is built on the premise that humans construe their realities. 
Experience can only be known through the structures and functions of the nervous system, 
which according to Hayek (1952) is primarily a classification system. The manner by 
which experiences are classified, rather than a lens from which to view the world, becomes 
a construct which drives a person toward the creation of experiences, definitions of those 
experiences, and ascription of meaning to those experiences. This proactive system of 
construing not only determines the output but also the input (Guidano, 1984). This is not 
to suggest, however, that the inner experience of "constructs" is an isolated system. 

Maturanna and Varela (1987) state that the ascription of meaning regarding the 
coordination of behavior occurs in the context of two or more people. But meaning is not 
always in the form of language. Meaning is socially constructed, an outgrowth of culture 
and context, and the process of assigning meaning goes beyond language and conscious 
categorization (Kelly, 1955). 

Lakoff and Johnson (1980) distinguish between conception and experience. 
Experience is direct interaction with the physical environment and bodily sensation and can 
occur without language. Conceptualization (perception) is grounded not only in this spatial 
experience and physical sensation but in a vast background of cultural presuppositions. 
Research suggests that people will change without conscious categorization of material. In 
a study by Langer (1989), a group of seventy-five year olds was placed in a retreat setting 



41 
retrofitted with objects characteristic of twenty years earlier. They were simply told, "Be 
fifty-five again." Within a week, the participants demonstrated incredible changes in 
dexterity, hearing, taste, height, IQ, and attitude as compared with a control group in a 
setting without the retrofitted environment. Although this phenomenon occurred within a 
social context, the effects of meaning were outside the realm of conscious construction and 
outside language. The participants' co-constructed meaning was influenced by the 
interaction of the physical environment and their formerly constructed understanding of 
what it meant to be fifty-five. 

It is quite likely also that the constructs of ill people and disease are unconsciously 
represented, are socially constructed and determine to a great degree the choices made 
regarding illness. How and with whom the information concerning one's disease is attained 
and processed will affect the patient and the disease. "Reality" is maintained by social 
processes and the presence of interaction is central to maintaining reality durine a crisis. 
The most important vehicle in the maintainance of this reality is communication. The role 
of language begins with labeling the experience and sharing that label with another person. 

Two processes are described by social constructionists that may influence the 
decision-making processes in a family when disease occurs: primary socialization and 
secondary socialization. Primary socialization consists of the information presented to us 
as children that we accept as "reality" without further scrutiny. Later in life, we are 
presented with other socialization messages garnered from our experience with other 
people. Berger and Luckman (1966) described secondary socialization as the acquisition 
of role-specific knowledge, internalized through the role-specific vocabulary. On both a 



42 
cognitive and an emotional level, a cohesive "reality" is internalized along with the 

institutionalized body of meanings that accompany the role. However, because this 

secondary socialization is imposed on an already formed primary socialization, 

discrepancies may arise between the two. For secondary socialization to take precedence, 

it must be reinforced. Berger and Luckman suggest that a person's social base serves as the 

laboratory for transforming the primary socialization, through strong affective bonds, to a 

secondary socialization. The family and friends of a cancer patient serve as this laboratory 

and the group mediates the illness experience. 

George Kelly (1955) postulated that people are "personal scientists." He stated 
that, "Man looks at his world through transparent patterns or templets which he creates 
and then attempts to fit over the realities of which the world is composed. The fit is not 

always very good These patterns are tentatively tried on for size" (Kelly, 1955, p. 42). 

It is through these attempts to fit experience to the constructs that the constructs are altered. 
This appears to be analogous to active decision-making and may be the most adaptive for 
effective coping and enhancement of treatment. 

An imaginary example to demonstrate this point is the story about George and 
Louise. George and Louise had been married for twenty-four years when Louise was 
diagnosed with breast cancer. Louise's grandmother had died of cancer when Louise was 
eleven. Louise doesn't know what kind of cancer. Visiting had come to a sudden halt and, 
for a long time, only her mother saw her grandmother. Just days before her death, Louise 
was told that her grandmother had cancer and was dying. As a result of this experience. 



43 
Louise's primary socialization around disease was formed: disease is not discussed, cancer 
leads to death, activity comes to a halt, and one isolates oneself when seriously ill. 

When Louise herself was diagnosed with cancer, she automatically fell into the 
pattern she had seen with her grandmother. She did not discuss the issue with her 
husband and halted her activities without explanation to others around her. The definition, 
means of coping, and expected outcomes of her disease were defined by the construction 
she had learned in childhood. Her story is an example of a cognitive commitment made to 
a pre-existing schema. 

After several months of depression while undergoing radiation, Louise was referred 
to a counselor. In the process, she and the counselor examined how she had arrived at the 
decisions about her illness. Together they began to construct new parameters for the 
disease. Louise began to question the silence with her husband. When she did discuss her 
cancer in depth with him. he told her a very different story about cancer learned from his 
childhood. Together they were able to reconstruct her decisions relating to her illness. This 
reconstruction is what Berger and Luckman would define secondary socialization. Her 
depression lifted, her radiation therapy worked and Louise is now a "Bosom Buddy." 
(Bosom Buddies is a nationally organized support group for women who have/had breast 
cancer.) 

Although perception plays a key role in coping and recovery, it is clearly influenced 
by cultural and individual factors. Schemata about events are formulated through our 
experiences embedded within a culture and then when faced with that event on a more 
personal level, a person's perceptions are heavily influenced by this existing schema. The 



44 
influence of this schema creates a frame from which the person actively construes the 
personal events as they unfold. It is from such a template and system of construal that 
decisions are made when a person faces a life-threatening illness. Acting upon perceptions 
and images requires making decisions. 

Decision Making and Illness 

Medical decision making has been viewed historically as a process carried out by 
the deliverers of medical services. The majority of contemporary literature reflects this 
stance. Considerable research has focused on physician judgement about illness and 
treatment (for example: Harris, Evans, Dennis, & Dean, 1996). A few studies considered 
patient variables in addition to the illness (for example: Mort, 1996). And many other 
studies investigated the effects of certain policy decisions affecting the delivery of services 
(for example: Larson, Christenson, Abbott, & Franz, 1996). 

Only two topics brought the researchers to consider the patient's decision-making 
process: the choice of when to seek treatment and the choice to die rather than treat. 
Research has been conducted on these topics since the early 1980's and is accruing. 
However, there are many decisions made in addition to seeking initial treatment and 
choosing to die. Yet this decision-making has been sorely neglected. In seventy-five 
articles published in psych-lit in 1997 on medical decision making (not including the two 
topics mentioned), only eight focused on decision making by the patient. In 1996, only six 
articles of the one hundred and sixty-nine published reflected the patient's point of view. 
Within the last few years, the medical literature contains more research, but many studies 



45 
still reflect the biased perspective of convincing the patients to make decisions in 

accordance with medical providers. 

Patients today are playing an increasingly central role in medical decisions that 
concern their well-being. However, what professionals believe are patient preferences 
often differ from what the patient really wants (Kane, 1996). Recent investigations of the 
choice to seek treatment reveal that the choice is more attitudinally based than symptom 
based. It was not the symptoms that prompted elderly patients in one study to seek medical 
treatment but the perception and causal attributions that proved to be the most predictive 
(Stoller & Forster, 1994). In another study (Hitchcock & Matthews, 1992), participants 
exhibiting more sensitivity to illness words engaged in more catastrophic thought about 
their illness and sought medical treatment more frequently. Life satisfaction was shown to 
be more predictive than symptomatic discomfort in determining level of functioning among 
chronic pulmonary disease patients (Cameron, LeventhaL & Leventhal 1 995; Leidy & 
Haase, 1996). 

Specific to decisions concerning cancer treatment, two factors were found to 
influence decision-making: the amount and specificity of recommendations and the 
strength of the recommendations (Siminoff & Fetting, 1991). The first refers to the ability 
of a patient to comprehend and store the recommendations in long term memory. The 
second, strength of recommendation, was found to be a factor influencing a patient's 
motivation to process the information effortfully (Petty & Cacioppo, 1986). Both of these 
clearly posit the decision-making power with the physician rather than the patient. In the 
Siminoff and Fetting study, eighty percent of the patients accepted the physician's 



46 
recommendations. Those who did not were more educated and considered themselves 
risk-takers. 



srms 



or a 



Information about medical choices is often presented in probabilistic ter 
(Kahneman, Slovic, & Tversky, 1982). Whether the problem is formulated as a loss 
gam influences the choices. The problem becomes socially constructed through language. 
For instance, one study investigated how medical decisions were influenced by whether a 
message was presented in terms of possibility of survival or morbidity. One experiment 
dealt with the choice of radiation or surgery for lung cancer; the other with the choice of a 
normal, risky, or abnormal pregnancy. People interpreted an ambiguous frame in highly 
selective ways that were in consonance with their values or beliefs. Those presented with a 
survival framework chose the riskier cancer treatment than those presented with a mortality 
framework. Fewer differences were found in the pregnancy decisions. Risk was more 
attractive in the positive frame than in the negative frame (McNeil Pauker, & Tversky. 
1988). 

A recent line of investigation queries whether patients wish to be involved in 
decisions about their treatment. Findings report that patients desire more involvement 
(Brody, Miller, & Lerman, 1989) and when they are involved, they report more 
satisfaction with their care(Valente, Antlizt, & Boyd, 1988), adhere to recommendations 
(Greenfield, Kaplan, & Ware, 1988), and experience better health outcomes (Greenfield, 
Kaplan, & Ware, 1985). In an investigation of women with breast cancer, 22% wanted to 
select their own treatment, 44% wanted to do so collaboratively with the physician, and 
34% wanted their physician to choose (Degner, Kristjanson, Bowman, Jeffrey, Sloan, 



47 
Carriere, O'Neill, & Bilodeau, 1997). Only 42% of the women felt they achieved then 

desired role in the decision making about their treatment. The majority of these women 

wanted more control, while 14.9% of those who felt dissatisfied believed they were 

"pushed" to assume more decisional control than they wanted. 

While the physician may make treatment decisions based on the symptoms and 
effectiveness of cure, the patient bases treatment decisions on a personal knowledge of 
his/her values and beliefs. In a study on men with prostatic hyperplasia, the possibility of 
sexual dysfunction predicted their decision about surgery (Barry, Fowler, Mulley, 
Henderson, & Wennberg, 1995). 

The results of these studies clearly indicate that decision-making for medical 
reasons is far from data-driven, is influenceable, and carries major consequences. Yet 
decision-making concerning medical issues is surprisingly neglected in the research 
literature. 

Some Decisional Styles May Enhance Coping 

The growing perception of medical services as a consumer product (Reiter, Lench, 
& Gambone, 1989) and the health component of the women's movement (Rodin & 
Ickovics, 1990) have increased research on physician-patient communication, focusing on 
the patient's role in decision-making. Active information sharing in decision-making 
process enhance the patient's perception of control and self-responsibility (Lerman, 
Broday, Caputo, Smith, Lazaro, & Wolfson, 1990). Patients actively involved in their 
decisions about treatment demonstrated improved health outcomes (Garrity & Lawson, 



48 
1989), less functional disability (Greenfield, Kaplan, & Ware, 1985), and faster recovery 
(Wallace, 1986). 

Increased adherence to medication regimens has been linked with the sharing of 
more information between physician and patient (DiMatteo, Hays, & Sherboume, 1992; 
DiMatteo, Sherboume, Hays, Ordway, Kravitz, McGynn, Kaplan, & Rogers, 1993). 
Although information exchange does not necessarily constitute active decision-making, it 
does indicate a higher level of involvement on the part of the patient. These studies were 
conducted on people's naturally occurring style of reacting to a medical situation. One 
study investigated the effects of changing patient's participation through participation 
training. Training focused on question-asking and participation in informed consent. It did 
not lead to greater satisfaction with their visit and other measures of treatment outcome 
were not assessed (Greenfield, Kaplan, & Ware, 1985; Roter, 1984). 

Even the perception of choice increases a sense of control which has been shown 
to positively affect health outcomes. Significantly more positive results have also been 
found when people chose their treatment than those who were not given a choice. Several 
studies gave people the identical treatment or protocols to follow, manipulating only their 
sense of choice. The groups of participants who attributed the choice to themselves 
responded more favorably to treatment (Gordon, Mendonca & Brehm, 1983), engaged in 
more healthful activities (Thompson & Wankel, 1980), and reported a reduction in anxiety 
and depression in response to a cancer diagnosis (Morris & Royle, 1988). However, the 
relationship exhibited in these studies are not so definitive when the perception of control 
variance is considered. The amount of perceived control over choice of treatment was 



49 
associated with the participants' prior beliefs about control over their health rather than the 
circumstances presented by the medical system (England & Evans, 1992). 

Having a choice and participating in one's medical decisions, as both active and 
passive decisional styles do, could lead to positive health outcomes. While decision making 
appears to be a critical factor in determining these health outcomes, evidence suggests 
individual differences rather than opportunity direct the process. 

Coping 

With the accepted theories of coping, two significant factors emerged: coping 
mechanisms actually reduce stress and that coping mechanisms act as a buffer in the face 
of stress. Lazarus and Folkman ( 1 984) conceptualized coping as consisting of four 
elements: stimulus, appraisal, response, and outcome. Coping involves purposeful 
thoughts and actions taken to reduce a threat. Coping is therefore a conscious decision to 
do or not do something. 

In this study, coping is viewed as a transactional model. Coping is situation and 
time-specific because it is constantly modified through appraisal and reappraisals of one's 
efforts and the situation. Coping is also individual and conforms to a generalized pattern of 
behavior in response to stress (Carver, Schenier, & Weintraub, 1989; Miller, Combs, & 
Stoddard, 1989). 
Cancer as the Stimulus for Coping 

Cancer has been investigated both as a generalized experience and as a condition 
having unique and specific demands. When viewed as a unitary variable, results are likely 
to be haphazard because it assumes that all cancers pose the same demands or the same 



50 
cancer poses the same demands on all individuals (Parle & Maguire, 1995). Evidence has 
been gathered indicating that coping with cancer is situation and time specific (Buddeberg, 
Sieber, Wolf, Landolt-Ritter, Richter, & Steiner, 1996). Inviting the patient to focus on the 
identification and response to one particular stressor elicits both the generalized pattern and 
the situation-specific response. The current study uses the latter approach. Specific stimuli 
demands that may trigger a need to invoke a coping strategy are severity (Aldwin & 
Revenson, 1987), controllability (Smith, Ackerman, & Blotcky, 1989), threats to self- 
esteem and self-identity (Curbow & Somerfield, 1991; Curbow, Somerfield, Legro, & 
Sonnega, 1990), threats to the integrity of the body, threats to quality of life (Mattlin, 
Wethington, & Kessler, 1990), threats imposed by limitations of treatment or illness, and 
inadequate social supports (Blanchard, Albrecht Ruckdeschel, Grant, & Hemnick, 1995). 
Coping Appraisal 

Appraisal includes both the individual's judgement on the threat (primary anpraisal) 
and the recognition of what options exist to manage the threat (secondary appraisal). 
Subjective appraisal has been found to play a significant role in coping (Dunkel-Schetter, 
Feinstein, Taylor, & Falke, 1994; Folkman, Lazarus, Dunkel-Schetter, Delongis, & Gruen, 
1986; Lazarus & Folkman, 1984). Maladaptive coping strategies were initiated in cervical 
cancer patients who selectively attend to negative features (MacLeod & Hagan, 1992). In 
another study, patients were assessed upon diagnosis about their worries and expectations 
for the cancer and coping. Those who used a negative assessment demonstrated 
significantly higher levels of affective disorders eight weeks later (Parle, Jones, & Maguire, 
1994). In fact, appraisal has been shown to be more predictive of effective coping than the 



51 
state of the illness (Dunkel-Schetter et al, 1992). Among cancer patients, a positive 

reinterpretation of the illness has been associated with reduced distress and a coping 
strategy of escape-avoidance has been associated with increased distress. Appraisal is 
clearly a pivotal mediating factor in coping. 

One domain, attribution of causality, in which appraisal operates, is significant to 
coping. Attributions made in response to disease operate independently of the usual 
attributional style of the individual (Moulton, Sweet, Temoshek, & Mandel, 1987) and 
change over time (Schoeneman & Curry, 1990). Health attribution does not appear to be a 
stable feature but situation specific. How are health attributions determined? Social 
influence offers a possible answer; important to effective coping is the availability of 
partners to provide feedback on daily changes (Monge, 1982) and re-evaluation of the 
couple's common goals (Stetz, Lewis, & Primono, 1986). 

Another domain determined by apDraisal is self-efficacv. Studies on self-efficacy 
in coping have investigated coping variables that promote resolution of a specific aspect of 
the illness. Different patterns of coping were found in dealing with cancer-related 
problems than with other life problems (Cook-Gotay, 1984; Meyerowitz, 1983). Diet 
(Caesar & Tucker, 1991), distressing medical procedures (Litt, 1988) and coping with 
chemotherapy (Miller, Combs, & Stoddard, 1989) have all been shown to improve with 
increased self-efficacy. 
Response to Coping: Coping Strategies 

The idea that coping be viewed as a process rather than a trait fostered research 
focusing on specific strategies and the discovery of delineated patterns of coping. Less 



52 
distress was demonstrated in cancer patients who used a more positive or confrontational 

approach to their illness (Burgess, Morris, & Pettingale, 1988; Feifel, Strack, & Nagy, 

1987a). In contrast, those patients using avoidance and acceptance-resignation 

demonstrated more emotional distress (Rodrigue, Boggs, Weiner, & Behen, 1993). A 

positive reinterpretation of the illness experience (Felton, Revenson, & Heinrichsen, 1984) 

and more problem-focused coping (Billings & Moos, 1981) resulted in less distress. In the 

most extensive coping study conducted on 668 cancer patients, cognitive appraisals of 

stress were associated with three of the five coping patterns. Emotional distress was 

associated with focusing on the positive and escape-avoidance coping (Dunkel-Schetter, 

Feinstein, Taylor, & Falke, 1992). 

Patients who mentally prepared themselves for chemotherapy took actions to 
reduce the threat. Those who avoided thinking about it reported increased anxiety which 
led to unsuccessful actions to reduce their stress. The action taken bv avoiders was not 
adaptive while that taken by the cognitive coping group reported less distress and improved 
adaptation (Lev, 1992). 

In contrast, some studies found that both the cognitive approach to coping and 
avoidance reduced stress (Manuel, Roth, Keefe, & Brantley, 1987). But, these results 
were found immediately after diagnosis. When measured over time, stress increased in the 
avoidance group and decreased in the cognitive group. In a study by Dean and Surtees 
(1989), time was also reported as a factor in coping effectiveness with very different 
results. They found that women with breast cancer were more likely to remain disease free 
during an eight year follow-up period if they reported using denial more than other coping 



53 
strategies. The coping strategies denial was compared with were hopelessness/helplessness 
or stoic acceptance, neither of which could be considered a cognitive coping strategy. In a 
replication of this study (Buddeberg, Sieber, Wolf, Landolt-Ritter, Richter, & Steiner, 
1996) the results were inconclusive with the exception of the discovery that patients use 
different patterns of coping over time. In an exploration including both individual patterns 
of coping and situation specific patterns of coping, Carver, Scheier, & Weintraub (1989) 
suggested that coping is determined by the "fit" between an individual's preferred way of 
coping and the demands of the situation. Flexibility has been identified by other 
researchers as essential in coping with illness demands (Rowland, 1989; Dunkel-Schetter et 
al, 1992). 

Outcomes of Coping 

Two types of outcomes have been explored. The first is the relationship between 
'eve! of distress or affective disorder and cooine stratesies. The second is wosression and 
recurrence of illness, or survival rates. Many of the earlier studies on coping with cancer 
measured distress broadly and found little relationship between coping and cancer 
outcomes. However, when the dependent measures were specific to certain types of 
distress and independent variables were measured for specific ways of coping, the results 
indicated a relationship. 

Other outcomes measures of coping were physical in nature. Patients using 
cognitive coping strategies required significantly less pain medication and reported less pain 
following cancer breast surgery than those using affective strategies ( Jacobsen & Butler, 
1996). Men with HIV who used a "fighting spirit" coping style were found to have fewer 



54 
HIV related symptoms one year later (Mulder, Antoni, Duivenvoorden, Kaugmann, & 

Goodkin, 1994; Solano, Costa, Salvatis, Coda, Auiti, Mezzaroma, & Bertini, 1993). In a 

ten and fifteen year follow-up study of women with breast cancer, fighters and deniers 

were more than twice as likely to be alive than those who felt hopeless and helpless (Greer, 

Morris, Pettingale, & Haybrittle, 1990). 

By studying the underlying mechanisms, such as decision-making, which may 
influence the choice of coping strategies utilized, understanding of the complex nature of 
coping may be advanced. 

Integration Of Mindfulness and Social Influence Theories 

"Attitudes structure one's social universe and, in so doing, ease decision-making" 
(Fazio, 1995). Gordon Allport (1935, p. 806) stated, 

"Without guiding attitudes the individual is confused and baffled. Some 
kind of preparation is essential before he can make a satisfactory 
observation, pass suitable Judgement, or make any but the most primitive 

Attitudes provide the benchmark against which to weigh options. The following 
review of the research indicates that the postulates of both Langer's theory of mindfulness 
and Petty and Cacioppo's elaboration likelihood model (an attitude change theory) describe 
a strikingly similar process. Research supporting both theories has demonstrated similar 
variables affecting the processing of information. The strength of Langer's theory is the 
research in applied settings and the strength of Petty and Cacioppo's theory is the enormous 
amount of research support it has garnered. Integrating these theories provides evidence of 



55 
three decisional styles and two routes of processing as well as the variables influencing 
which route of processing is likely to be used. 

In spite of an obvious link between attitude and decisions, because of having 
different goals in their research, the attitude theory literature and decision making literature 
rarely directly address this connection. Because of the link between socially constructed 
attitudes and relatively individual decision-making, it is theoretically logical to use both in 
an investigation of medical decision-making. This integration is further supported by the 
parallels found in the research on both the theory of mindfulness and attitude change 
theories. The postulates and their supporting evidence result in a common explanation for 
decision-making behavior. But theoretical consistency is not the only reason to integrate 
these theories. Practically speaking, the theory of mindfulness provides explanations for 
different styles of deciding when the message is uncontrollable (as in natural settings), 
while the social influence models provide a well-researched mechanism of change. The 
implications of using both for this study are that these theories may be expanded, will be 
tested in a "real world" serious threat situation, and should provide information in 
developing programs to assist people in efforts to cope with cancer. 

One of the earliest and most researched of these attitude change theories is the 
elaboration likelihood model of attitude change. After culling through the inconsistent 
results of a decade of research on attitude change, Petty and Cacioppo (1981) identified 
two modes of processing: central and peripheral. In integrating the attitude change 
research, Petty and Cacioppo placed the findings on a continuum ranging from low 



likelihood to evaluate a message (peripheral route) to high likelihood to evaluate 



a message 



56 
(central). The low end is dominated by theories such as classical and operant conditioning 

and the high end dominated by theories emphasizing issue-relevant thinking, an example 
being Ajzen and Fishbein's theory of reasoned action (1980). Because of its inclusiveness, 
the elaboration likelihood model (ELM) provides a powerful framework for organizing and 
integrating these theories. 
Decision Making and Different Modes of Processing 

Conventional wisdom judges a "good" decision as one that has a "good" outcome. 
What then does a person do when the outcome is unpredictable? When the expected 
"good" outcome does not occur, does that mean the decision was "bad" and the decision 
maker "wrong"? Decision theorists suggest that the way a person makes a decision is far 
more crucial to this determination than outcome analysis. A cost-benefit analysis based on 
information gathered and then formulated into a problem to be solved leads to the best 
decision possible at the time. 

Langer's theory (1994) suggested that people will arrive at a decision when they 
make a cognitive commitment, not when all the costs and benefits have been weighed. 
"Cognitive commitments are frozen or rigidly held beliefs that unwittingly are unmodulated 
by context" (Shank & Langer, 1994, p. 34). She suggested that the cost-benefits 
perspective is postdecisional and used merely to justify the choice. In a study, Klein and 
Kunda (1992) manipulated participants' motivation to see a person as more or less capable 
by being told the person was going to be their opponent or their team member. Although 
they had no basis forjudging this prior to their stated assessment, they post-decisionally 
constructed rational justifications for their choice. 



57 
According to Langer, the dynamic process of choice is characterized by instability 
and uncertainty. Uncertainty drives a person to either gather information or induce stability 
by making a cognitive commitment. There is no natural end point to information gathering 
and a search ends when the person settles on a cognitive commitment. 

The decision itself is automatic, i.e., not calculated. Information can be gathered 
but it does not inform us of our preferences. Our preferences are that which is stable. 
Stable preferences suggest a predetermined mindset that influenced the decision. When a 
mindset or schema is reached or constructed, the choice is made. 

In this way, Langer viewed decision making not as a continuum or dichtotomy of 
rational vs. irrational, but as arational. She distinguished two forms of decision making: 
mindful and mindless. Mindful decision making (also termed active deciding) consists of 
self-awareness and the generation of new options based on information given or gathered. 
A choice is made from among that expanded list of choices. In the mindful condition, the 
information integration and gathering continues until one choice is psychologically different 
for the person. Schema still governs this process but it is broad enough to allow the 
investigation to continue until a cognitive commitment is made to a choice after effortful 
consideration. 

Attitude change theorists also identified two modes of processing. Petty and 
Cacioppo (1981) called these modes central and peripheral route processing, Chaiken 
(1984) called them heuristic and systematic, and Fazio (1995) described them as automatic 
activation and effortful, deliberate processing. All three theorists agree that central route, 
systematic, and effortful deliberate processing are the same. Central processing depends 



58 
on the amount of elaboration or effortful thinking a person is willing to engage in. Petty 

and Cacioppo (1986, p. 14) state, "elaboration means the process of relating the to-be- 
evaluated recommendations and arguments to other issue relevant information in 
memory.... (resulting) in self-generation of information unique to externally provided 
communication." The similarities to Langer's description of mindfulness (active deciding) 
are clearly evident. 

Petty and Cacioppo (1986) interpreted mindfulness vs. mindlessness as automatic 
vs. controlled processing. They said that central route processing is a particular kind of 
controlled processing conducted for the purpose of evaluation. The stated purpose of their 
research program was to understand a person's specific attitudinal reaction to a particular 
message. Because they chose a narrowly proscribed aspect of attitude change with which 
to conduct their studies does not preclude their theory being broad enough to apply to 
people's decision-making patterns in natural settings. 

Chaiken (1987) differentiated her heuristic/systematic processing from Petty and 
Cacioppo's central/peripheral route processing on only one dimension. She claims the 
distinction is that heuristic/systematic is a parallel processing mode occurring 
simultaneously, while central/peripheral route processing appears to be mutually exclusive. 
Fazio's research on strength of association explains the shift from one route to another. He 
stated that the association between the attitude and the object (or issue) in memory will 
determine the accessibility of that attitude in informing the decision. No studies were 
located that detected whether processing information occurs simultaneously or sequentially. 



59 
However, extensive research has been conducted manipulating conditons through which 
central and peripheral route processing was changed. 

Throughout social psychological literature a consensus has been garnered that 
people engage in mindless analysis (Craik, 1979;Eagly & Chaiken, 1984; Kahneman, 
Slovic, & Tversky, 1982; Langer, 1978; Schneider & Shiffrin, 1977). Petty and Cacioppo 
(1986) agree that people in natural settings use peripheral route processing far more than 
their laboratory experiments would lead one to believe. 
Evidence of M indlessness 

In study after study, Langer sought naturally occurring conditions to assess the 
degree of mindlessness engaged in by people. Much of her research has far-reachina 
implications for health. A recent study (Langer, Mueller, & Brown, 1993) compared 
hearing and hearing-impaired people. They hypothesized that the hearing impaired would 
have had less opportunity early in life to establish preconceived ideas on memory loss in 
the elderly and, therefore, would perform better on memory tests. If information cannot be 
retrieved from memory, a decision is more likely to be made by considering more carefully 
the current situation. The hypothesis was confirmed. 

Langer and Piper (1987) studied elderly adults who lived with a grandparent at age 
two and others at age twelve. The assumption was that those who lived with elderly people 
at a young age would have a preconceived schema about age that elderly people were 
strong and capable (a two year old's perspective) and those at age twelve would have a 
mindset of more fragile elders. She hypothesized that the group which had lived with 



60 
grandparents at age two would be stronger and healthier themselves as older adults. The 
hypothesis was confirmed. 

Many other researchers have demonstrated situations in which people do not use 
reasoned attribute-based analysis to determine a course of action but make decisions and 
perform tasks after only a minimal amount of processing (Abelson, 1976; Bargh, 1984; 
Chaiken & Yates, 1985; Cialdini, 1985; Craik & Lockhart, 1972; Langer, 1978; Petty & 
Cacioppo, 1981; Sanbonmatsu & Fazio, 1990, exp.2; Schneider & Shiffrin, 1977; Tesser 
& Leone, 1977). 

People rely primarily on previously formulated attitudes or schema. Evidence of 
such a pre-existing schema was obtained in a study by Tesser (1978), in which people were 
instructed to think about an issue. As they did their attitudes toward the issue became 
polarized in the direction of their initial tendency. 

Higgins and Stangor (1988) demonstrated that once a person associates a few cues 
with a schema, they will base their judgement on that schema as if all the properties of the 
new situation fit the original source properties. Changing the standard by which a situation 
is measured changes the schema and allows for increased scrutiny of the attributes of the 
situation (Higgins & Lurie, 1983). Langer (1994) describes a situation in which one may 
like apples more than oranges and both more than grapefruit. When using the schema of 
taste preference, one would choose apples over oranges. She further states that the 
direction is not transitive because one may invoke a different schema such as "more is 
better when it comes to food" and therefore choose grapefruit. 



61 
This organized schema was labeled by Chaiken (1984) as heuristic, i.e., simple 
decisional rules in order to ease processing without effortful thought. In four experiments 
measuring the effects of priming manipulations that vary accessibility or reliability of simple 
heuristics showed a consistent, albeit low statistical significance, that both accessibility and 
reliability of these simple decisional rules influence the likelihood that they will be used to 
evaluate a message (Chaiken et al, 1985; Hicks & Chaiken, 1984). Furthermore, priming 
effects were more pronounced for those participants who typically rely on heuristics in 
decision making. Although the effects were not statistically robust, they were consistent. 
The persuasion impact of cues which elicit the use of a heuristic are a function of 
the strength of their association. Fazio (1983) conducted four experiments in which the 
subjects were led to expect that they would have to answer questions on the messages 
presented. Condition one provided the cue of expectation prior to the message 
presentation, condition two provided the cue immediately after message presentation, and 
condition three provided no cues to consolidate the message. Spontaneous formation of 
attitudes occurred most frequently under the conditions of expectation cues provided prior 
to the message and no evidence of formation of attitudes occurred in the no consolidation 
cue condition. 

Developed and rehearsed attitudes were shown to be more predictive of decisions 
that were unlikely to be modified later (Fazio et al, 1992). The strength of the association 
between memory and the issue explains this predictive power. More frequent use of the 
association will increase its accessibility (Fazio, Sanbonmatsu, Powell, & Kardes, 1986). 
Rehearsing increases the associations between an attitude and an object (Fazio et al, 1982). 



62 
making it more likely to be invoked when a decision is needed (Fazio, 1989). Effortful 

thinking (Fazio et al, 1992, exp. 2) is avoided in this manner. This research conducted in 
four different laboratories all support the two routes of processing and the prevalence of 
mindless decision making according to pre-existing schema. But the parallels between 
mindfulness vs mindlessness and central vs. peripheral route processing are even more 
extensive. 

Cognitive Commitment 

Mindlessness is engendered by cognitive commitments made prematurely. 
Cognitive commitments are based on rigidly held beliefs or schemata. Such schemata are 
essential in managing the inestimable amount of information available at any one moment. 
A stable set of schemata enables the individual to make the world comprehensible and 
predictable (Bannister & Franzella, 1971). Once a schema is invoked, new information, 
unique context or unfamiliar aspects of a situation will be overlooked. Premature 
cognitive commitment is uncritical acceptance of a choice without considering other 
choices even possible. What is accepted as truth is not reconsidered (Langer & Imber, 
1979). 

In one early study (Chanowicz & Langer, 1981), cognitive commitments to 
symptoms of a fictional disease were induced. When this group was later told they had the 
illness, they reported the fictitious symptoms at a significantly higher rate than the group 
who took in the information more mindfully. In another study subjects were presented 
with information in either conditional or unconditional language. The hypothesis that 
unconditional language would lead to cognitive commitments was confirmed. Generating 



63 
options never occurred to the group presented information unconditionally (Langer & 
Piper, 1987). 

Evidence of cognitive commitment is seen in the work of Chaiken (1980) (Eagly & 
Chaiken, 1984; Taylor & Fiske, 1978). Assessing the impact of communicator likability by 
manipulating response and issue involvement, Chaiken found that when involvement was 
low, participants responded more to likability than to message arguments. Petty and 
Cacioppo replicated these findings in response to attractiveness (Petty, Cacioppo, & 
Schumann, 1983) and expertise (Petty, Cacioppo, & Goldman, 1981). Consonant with 
these findings, Langer, Blank, & Chanowicz (1978) found that subjects will comply 
mindlessly with a favor unless the favor requires too much effort. Although none of these 
studies directly assessed the underlying heuristic or commitment to a schema, there is 
evidence that unless a person is motivated to approach a situation with effortful thought, 
there is a high likelihood that he/she will respond mindlessly, making a premature cognitive 
commitment. 

Langer identified three types of cognitive commitments. The previously cited 
research is representational of the first, i.e., a personal commitment to content. The second 
type occurs when a personal belief is not available, resulting in a cognitive commitment 
likely to be made to a societal commitment to content. For example, when a medical 
illness strikes, a person will make decisions based on vicarious learning and information 
from a referrent group (Monge, 1983; Rodin & Janis, 1979; Stetz, 1986). Most often the 
referrent group is the family. When others are perceived to hold the same attitude, 
confidence in its validity is increased (Holtz & Miller, 1985). 



64 
Evidence from studies on multiple source effects within the ELM support Langer's 
contention. Harkins and Petty (1981) demonstrated that participants hearing three 
different arguments advocating a position from three different sources were more 
influenced than those hearing three arguments from one source. In a follow-up study 
(Petty & Cacioppo, 1981) findings suggested that increased elaboration occurred when the 
arguments came from multiple sources due to further elaboration when each argument was 
presented. This effect was shown to increase when the participants were presented as 
independent rather than from one cohesive group (Harkins & Petty, 1987). These studies 
suggest that people do elaborate more when information is presented by multiple sources 
and this effect is increased when the sources appear independent. These findings support 
Langer's theory stating that when a person does not arrive at a decision based on a 
cognitive commitment previously held, the individual is likely to arrive at a societal 
decision. It also suggests that to effectively deliver a message to a cancer patient say to 
increase adherence, several arguments from several sources will enhance adoption of the 
suggestions. 

In the third type of cognitive commitment, a person uses an existing schema to 
guide decision-making. A process schema dictates factors such as the number of 
questions asked, the amount of time spent deciding, and the type of resources consulted, 
prior to making a cognitive commitment. Although this process commitment is relatively 
stable for an individual, it may also include varying degrees of effort, depending on 
situational seriousness. Unless this process commitment is flexible enough to leave a 



65 
question open long enough for a personal or societal commitment to be made, the decision 
will end before true relevance for the individual is established. 

Eagly and Chaiken (1984) expanded on the concept of processing in response to 
cues by introducing the idea of heuristics, simple decision rules that are invoked in the 
absence of motivation and ability to process more effortfully. Sufficiency principle 
indicates that people will move from less effortful processing to more effortful processing. 
The reverse is also true (Wood & Eagly, 1981). In a series of experiments, Chaiken 
(1980) found that participants used simple decisional rules, particularly when presented 
with minimal information on the topic. These participants refrained from effortfully 
thinking about the validity of the information and relied on the credibility of the source in 
forming their opinions. 

In a study assessing factors affecting treatment decisions for a life threatening 
illness, eighty percent of the oatients accepted the physician's recommendations. Factors 
influencing their acceptance were the amount and specificity of the instructions and the 
strength of the recommendation. More importantly, non-acceptors were better educated 
and tended to be risk-takers (Siminoff & Fetting, 1991). The self-proclamation of risk 
taker is an example of a process schema such as, "I make my own decisions." which may 
govern their decision about how to treat an illness. 
Cognitive Commitments Are Made When Options Become Psychologically Distinct 

The importance of cognitive commitments cannot be underestimated since 
preferences are only stable once a commitment is reached. Langer (1994) views this as a 
correction to one of the thorniest problems in any rational decision theory, that of 



66 
systematic preference reversals (Cohen & March, 1974; Tversky & Kahneman, 1983). 

Attitude change research came close to being abandoned in the seventies because of the 
inconsistencies in the research attempts at explanation. Cialdini, Petty , and Cacioppo 
(1981) and Eagly and Himmelfarb (1978) began a series of studies aimed at understanding 
these discrepancies. They saw evidence of cognitive commitments, both enduring and 
transient, which they sought to explicate through studying the conditions under which each 
operate. 

Langer's hypothesis was supported in a study investigating conditional and 
unconditional presentation of information to contact lens buyers. While in the store one 
group was given information about one lens solution, another group was given information 
about two lens solutions. Several months later, they were all contacted by phone offering 
them a consumer opportunity. The only difference between the lens solution now being 
offered and the original one was the price. Only those who had not formed a cognitive 
commitment tried the new solution (Langer & Li, 1994). In another study by Cacioppo, 
Petty, and Sidera (1982) participants generated more topic relevant thought when the 
message was congruent with their self-schema about professed attitudes than when the 
message was incongruent with this schema. 

Langer (1994) stated that a person will entertain the message until options become 
psychologically different from each other. The psychological difference is highly 
idiosyncratic. The decision will be made when one of the avenues to a cognitive 
commitment is accepted. Such commitment then renders meaningful any consistencies 



67 
found in the environment. These experiences become relevant and will be used to 

strengthen the commitment (Craik & Lockhart, 1972). 

To understand how the ELM supports the idea that a decision will be made when 
psychological differences are noticed and considered relevant, the research addressing its 
application to counseling must be considered. In a review of the ELM applied to 
counseling literature, Heesacker, Conner, & Pritchard (1995) addressed the issue of 
change. Although peripheral-route-processed information may change attitudes, the 
change is not enduring (Petty & Cacioppo, 1986). Only centrally processed material 
promotes enduring change. This suggests that a preexisting cognitive schema will 
determine the decision until a person has the motivation to put forth effortful thought. 
Until then, peripheral cues consistent with the pre-existing schema will dominate the 
decisional process, and is analogous to a decision ending in premature cognitive 
commitment. Change will only take place when the nerson is motivated and enabled to 
engage in recognizing and reconsidering the old schema. Essential to understanding what 
occurs when a person switches from peripheral to central route processing is recognizing 
the idiosyncratic thoughts which support the preexisting schema and assisting the client to 
generate arguments that dismantle the ineffective schema which will allow for a new 
schema to be built. The erection of a new schema enables options to become 
psychologically different in ways not previously entertained and enables an enduring choice 
associated with a new schema to be made. 

Langer stated that the commitment can be made to either content or process. 
Included in the new schema can be clues as to when to re-examine the parameters of the 



68 
new schema, thereby instilling a commitment to process which overrides the commitment 
to content, increasing the person's flexibility. 
Categories of Decision Making 

Langer (1994) described three categories of decision making: active deciding, 
passive deciding, and premature committing (mindless deciding). The categories she 
established for decisional-styles are discriminated from each other by how decisions are 
made and by the point at which the commitment is made. Active deciding consists of 
generating options and choosing from among those options. Option generation will 
conclude only when enough information is gathered to discriminate in terms of the person's 
preferences (i.e. the options are psychologically different from each other for that person). 
Passive deciding involves choosing between only those options presented without 
generating others based on personal awareness. The choice is settled when a commitment 
is iriade to one of those choices. Larder's third category of decision makers is mindless 
deciding, which is the form most often used. 

Most research on decision making has been conducted on passive decision-making 
because laboratory studies use only a finite number of options and rarely allow for a 
creative participant to generate new options. Many of Petty and Cacioppo's studies (for 
example, those using a semantic differential) assess evaluation of a message through 
methods which limit the participant to responding to message options, but many others use 
a thought-listing procedure that enables the participant to generate options on their own. 
Petty and Cacioppo (1986, p. 14) stated that "elaboration means the process of relating the 
to-be-evaluated recommendation or arguments to other issue-relevant information in 



69 
memory," resulting in self-generation of information unique to externally provided 

communication. Their work supports the idea that central route processing is synonomous 
with Langer's active and passive deciding. This point is critical in supporting the 
assumption that it is possible to combine the work of Petty and Cacioppo and that of Ellen 
Langer. 

Passive vs. active deciding was demonstrated in a study investigating conflict 
situations (Langer & White, 1992). In one situation, the participants were instructed to 
settle their differences without using compromise. This approach forced the pairs to 
elaborate on a solution until a win-win situation was found. Subjects not instructed in this 
manner used the compromise solution which required less effortful thinking. Another 
study (Langer & Williams, 1992) asked participants to make a donation to a homeless 
shelter. One group was asked for a particular amount but not restricted from donating a 
different amount: the other was asked to actively decide the amount given. Both crouns 
had an equal number of donors but the ones who actively decided the amount gave more. 
The latter group also reported less post-decision regret. 

The third category, mindless choosing, is foreclosure on a preexisting schema. 
Premature foreclosure on a decision is devoid of active, ongoing information processing. 
Petty and Cacioppo describe this kind of processing as peripheral route processing, highly 
influenced by extraneous cues. For instance, a premature cognitive commitment is more 
likely to be made when information is given by an authority (Chanowicz & Langer, 1981; 
Langer, 1988). In this category, decisions are based on peripheral cues (Petty & Cacioppo, 
1986) or heuristics (Chaiken, 1980; Eagly & Chaiken, 1984). Once a person acts on these 






70 
arbitrary decisions, the choice begins to operate as a schema because the person infers an 
attitude from their behavior (Fazio & Zanna, 1981). 

Reducing uncertainty may be the goal of mindless deciding (Langer, 1994). The 
dimension of uncertainty was labeled and extensively researched by Kruglanski and 
Webster (1991, 1993, 1996) as a need for closure. Kruglanski (in press) defined the need 
for closure as the desire for definite knowledge and an aversion of ambiguity. The term 
"need" is borrowed from Cacioppo and Petty (1982) and identical in its meaning. It refers 
to a need for closure on the question and often any answer, rather than the "best" answer, 
is all that is required. 

Need for closure can be an individual trait or situationally induced. A person high 
in need for closure generates fewer options, makes judgements based on inconclusive 
evidence and, once committed to a decision, is relunctant to entertain the possibility of 
alternatives based on new information. In fact, new information is no* even noticed. After 
such a rigid commitment to a decision, individuals report more certainty in their choice 
than individuals low in need for closure. There is theoretical consistency between Langer's 
mindless deciding and Kruglanski's need for closure construct. The evidence supporting 
the need for closure construct will be addressed in the subsequent section of this chapter. 

Because premature commitments are so prevalent, information gathering may often 
be motivated by a need to explain and justify the decision after the fact rather than utilizing 
the information to think carefully prior to making a decision. Petty (1986) actually cautions 
the researcher by suggesting that the cognitive strategies demanded by the responses used 
in measuring may color the results. 



71 
Necessary Conditions for Mindfulness 

There is a considerable body of research conducted by all these theorists about the 
conditions under which a person will use one route of processing or the other. In this 
body of accumulated knowledge there are no studies which refute any of the others' 
theories. Research promoting one idea supports the others. Apparently, the differences 
are in the researchers' foci of attention and semantics. 

In the theory of mindfulness, Langer (1989) stated that people will operate 
mindlessly unless the following conditions exist: 1) a new situation involves novelty for 
which no cognitive commitment exists, 2) mindless deciding is more effortful than mindful 
deciding, 3) deciding is interrupted by external events that do not allow for completion of a 
commitment, 4) the experience leads to significantly discrepant consequences than those in 
the past, 5) there is insufficient involvement in the situation to warrant any reaction and 
therefore a schema is never invoked. 

The most thorough investigation of these factors was conducted on the ELM. 
Petty and Cacioppo (1986) found three pivotal factors encompassing many other variables. 
These factors are motivation, cognitive responding, and ability. 
Motivation 

Motivation is requisite in determining message scrutiny . The factors influencing 
motivation are personal relevance, involvement, personal responsibility, multiple sources, 
and individual need for cognition. In a review of motivation studies across theorists, Fiske 
and Neuberg (1990) concluded that when people had motivation to assess a message, they 



72 
were data-driven in their analysis; when people lacked the motivation, they were theory- 
driven. 

Petty and Cacioppo consider the most important variable affecting motivation to 
process centrally is personal relevance. Issue-relevant elaboration results in new options 
and their integration into one's schema (Petty & Cacioppo, 1984). Active deciding would 
also depend on personal relevance. Langer, Blank, and Chanowicz (1978) conducted a 
study in which students were asked to give up their turn at a copy machine. Small requests 
were accepted without reasons but large requests required a reason. The large requests 
increased the personal relevance by making the student wait, thereby increasing their 
motivation to think about the request prior to granting the favor. 

Manipulating advocacy or counterattitudinal messages in tape recordings, students 
were asked to report their views on a taped message (Petty & Cacioppo, 1979). Half the 
students were told that the message applied to their own university while the other half 
were told it applied to a distant college. Subjects in the high involvement condition 
(implementation at their own university) generated predominantly favorable thoughts to the 
proattitudinal message and predominantly unfavorable thoughts to the counterattitudinal 
message. Replications (Petty, Cacioppo, & Heesacker, 1981 ; Petty, Cacioppo, & 
Schumann, 1983) have been conducted that support the idea that, as personal relevance 
increases, people engage in more effortful thinking. 

When applying the personal relevance issue to a natural setting, there are several 
caveats to consider: first, if personal interests are intense, processing may be conducted in 
service to an individual's core constructs and may be biased or terminate (Greenwald, 



73 
1981). Second, issues truly relevant to an individual may have been given enough prior 

thought that expending more energy on thinking is perceived to be useless. Third, people 

often seek information about relevant issues and may have an increased store of prior 

knowledge (Petty & Cacioppo, 1986). Should this thought have already been generated by 

the individuals in this study, it will only enhance the study by serving as a discriminator 

between categories of decision-making styles. 

Related to relevance is involvement, another motivational variable which mediates 
thorough processing of information. Johnson and Eagly (1989) distinguish between three 
types of involvement which have a distinctly different effects on information processing. 
The first is value-relevant involvement, the activation of attitudes which are linked to core 
values. The higher the value relevant involvement, the wider the rejection range of the 
message (Sherif, Sherif, & Nebergall, 1965). The second type is impression-relevant 
involvement concern for self-presentation in the responses. The expectation of public 
scrutiny of one's views leads to assuming a more moderate, flexible, and less polarized 
position when the audience's opinion is unknown (Cialdini & Petty, 1981; Cialdini, Levy, 
Herman, & Evenbeck, 1973). Third, outcome relevent involvement (Petty & Cacioppo, 
1979), originally referred to this as issue-relevant involvement) refers to the degree to 
which the issue personally affects an individual's current goals. This type of involvement 
increases the likelihood of elaboration (Chaiken, 1980; Petty, Ostrom, & Brock, 1981). 

In a meta-analysis, Johnson and Eagly (1989) found that value-relevant 
involvement typically inhibits attitude change. Outcome relevant involvement, the most 
extensively researched of the three, showed no main effect and interacted with strength of 



74 
argument. Strong arguments persuaded, weak ones did not. However, whether effortful 
thought created this change in attitude in one condition and not in the other is unknown. It 
is just as possible that after thinking about the weak arguments, a mindful decision was 
made to retain one's position. 

Petty and Cacioppo (1990) took exception with this meta-analysis, stating that 
personal importance and not which aspect of importance is what determines relevance. 
They made a distinction between the intensity of information processing and the direction 
of that processing, each comprised of separate variables. In testing this hypothesis, Petty 
and Cacioppo (1986) have shown that as the intensity increases, the quality of arguments 
account for more variance. With no bias, strong arguments increase elaboration and weak 
arguments decrease elaboration. In unfavorable biased condition, strong arguments had no 
impact on elaboration and weak arguments reduced elaboration. They conclude that the 
extent of personal importance increases the extent of information processing. 

The literature on outcome relevant involvement has limited use in this study. The 
issues chosen for these studies were minor to moderate college related issues presented to 
undergraduate students. There are tremendous differences between still-dependent average 
undergraduate students and adults of all ages. The life and death issue faced by the 
participants in this study cannot be accurately compared with issues such as a format for 
exams or sharing dormitory space. Yet the most likely, outcome-relevant involvement is 
the type that is of greatest concern in this study and, as such, has an effect on motivation. 

Stable, intrinsic differences exist among individuals in their motivation to process 
information effortfully (Cacioppo & Petty, 1981, 1984; Cacioppo, Petty, & Morris, 1983). 



75 
Some people simply enjoy thinking more than others. This construct has been defined as a 
need for cognition. Need is viewed not as a deficit or having tension reduction goals but as 
an intrinsic desire. Taylor (1982) coined the term "cognitive misers" for people low in 
need for cognition. The concept of cognitive miser could account for the frequency of 
mindless deciding evident in Langer's and Chaiken's research. 

Individual differences were found between university professors (assumed to have 
high need for cognition and assembly line workers (assumed to have low need for 
cognition). Those high in need for cognition generated more thoughts than those low in 
need for cognition. In a group brainstorming task, participants low in need for cognition 
generated fewer ideas when they shared responsibility to create a list than when they were 
held personally responsible (Petty, Cacioppo, & Kramer, 1985). In further testing of this 
construct, need for cognition was found to be unrelated to intelligence in both abstract 
reasoning and verbal reasoning (Cacioppo, Petty, & Morris, 1983; Eagly & Warren, 1976). 

In a series of three experiments (Cacioppo, Petty, & Morris, 1983) determining 
how need for cognition affects message processing, findings demonstrated that individuals 
high in need for cognition were more likely to extract information and think effortfully 
about a message than those low in cognition. However, it would be inaccurate to assume 
that this individual characteristic is so intransigent that it cannot be overridden by situational 
factors. The meaning and implications of a decision will have a strong impact as well as 
message presentation and prior knowledge. Need for cognition is neither a necessary nor 
sufficient cause of message elaboration. 



76 
Ability 

If a person is to carefully evaluate a message using central route processing, the 
individual must have the ability to do so. Some persons may have greater ability than 
others and certain situations facilitate ability more than others. Distraction, message 
repetition, recipient posture, forewarning, argument strength, relevance of message, and 
time to consider have all been found to influence message processing ability. 

In a series of four experiments, Petty, Wells, and Brock (1976) demonstrated that 
distraction made processing more effortful. Unfavorable responses were increased as 
distraction increased, but, the number of unfavorable responses increased significantly 
more for messages with weak arguments than for those with strong arguments. High 
distraction reduced the number of unfavorable thoughts for the weak message but not the 
overall message and the number of favorable thoughts for the strong message. Attitudinal 
effects were most evident in the low and medium ran?e of distraction. Other reoHcations 
(Lammers & Becker, 1980) were consistent in their findings that distraction disrupts the 
thoughts that would normally be elicited by a message. Distraction inhibits ability 
especially when the motivation is high (Petty & Brock, 1981). Interference during message 
presentation decreases elaboration likelihood as well (Petty, Cacioppo, & Heesacker, 
1981). Langer-s theory states that if deciding is interrupted, a cognitive commitment is not 
made. 

Repetition: Moderate message repetition theoretically should enhance message 
acceptance since it extends the time an individual has to attend to the message required in 
any new learning situation. Repetition of verbal stimuli has been shown to increase likin* 






77 
in some studies (McCullough & Ostrom, 1974) and decreasing liking in others (Crush, 
1976). Petty and Cacioppo (1979) proposed that message repetition elicits a two-stage 
reaction. Repeated presentations provide the recipient with extended opportunity to 
evaluate and think about the message during the first stage. Tedium sets in when a person 
has exhausted associations to think about and the second stage elicits a negative reaction. 
Argument strength was again a factor. Moderate repetition of strong arguments led to a 
favorable response; moderate repetition of weak arguments led to more negative attitudes 
(Cacioppo & Petty, 1985). 

Physical cues: Based on the close association between cognition and body cues, 
recipient posture was explored. In a series of experiments (Petty, Wells, Heesacker, Brock, 
& Cacioppo, 1983), reclining subjects expressed more agreement than standing subjects. 
However, comfort was not the intervening variable since those who were seated reported 
being the most comfortable and vet had insignificant message agreement. Strop? ind weak 
arguments were not differentiated by the standing subjects. Other physiological factors 
involved in message elaboration are heart rate (Cacioppo, Sandman, & Walker, 1978) and 
right brain activity (Cacioppo, Petty, & Quintarar, 1982). 

Comprehension: Assessing ability in the absence of motivation is difficult. In one 
study (Ratneschwar & Chaiken, 1986), the researchers attempted to manipulate ability to 
process systematically (centrally). They manipulated comprehensibility by using a written 
description of a novel product with or without an accompanying picture. (The product was 
relatively undiscernable without picture.) Subjects in low comprehensibility condition 
manifested less comprehension and was more easily influenced by the peripheral cue of the 



78 



inventor is status in rating the usefulness of the product. When the comprehension was 
medium or high, participants rated usefulness based on the attributes of the product and 
reported more effortful thinking in a debriefing. 
Comparisons/Similarities 

Extensive similarities exist between the social influence theorists, Petty, Cacioppo, 
Chaiken, and Fazio and Langer's theory of mindfulness. Ellen Langer researched decision- 
making processing by focusing on the person making the decisions. The social influence 
theorists researched the interaction between people by focusing on particular messages and 
their effects on a person's processing. In researching these distinctly different topics, each 
has resulted in strikingly similar findings. 

Both the processes involved explained by each of these theories and the ensuing 
research variables are similar. The semantics are different but the theories support each 
other Two routes of processing has been proposed in all these theories. Langer calls these 
routes mindfulness and mindlessness; Petty and Cacioppo call them central and peripheral 
route processing; Chaiken and Shelley call them heuristic and systematic; Fazio calls them 
automatic activation and effortful, deliberate processing. The authors draw find 
distinctions between the routes of processing they describe and those of the other theorists, 
however, the differences described are a result of the focus of their research rather than 
any qualitative difference. 

The research variables that may affect processing independently chosen for 
exploration by each theorist are also surprisingly similar. The largest body of research on 
different variables was conducted on Petty and Cacioppo's ELM, chosen for use in this 



79 
research. With the exception of relevence and individual differences that may affect 

processing, Langer's decision making research and Petty & Cacioppo's social influence 

research investigated the identical variables in very different ways, resulting in identical 

findings. 

An integration of these theories is used for this research in order to draw upon the 
strengths of each. The topic under discussion in this research is decision making. The 
reason for studying this topic is to understand how a person's decisions about medical 
treatment affects coping and the variables which may improve coping. Langer's theory is 
provides a decision making theory that has been researched in applied settings with medical 
and other physical conditions. Petty and Cacioppo's theory has a demonstrated ability to 
both identify and change core attitudinal processes through changing the route of 
processing. How a person processes information related to medical conditions and arrives 
at a decision may affect his/her ability to cope. 

Evidence of a Fourth Decisional Style - Ruminating 

Ellen Langer (1994) identified three decisional styles: active, passive, and mindless 
deciding. However, she also stated that a person will entertain a message until options 
become psychologically different from each other. The decision is made when one of the 
avenues to a commitment is accepted as the "best option". 

The purpose of making a cognitive commitment is to reduce uncertainty (Langer, 
1994). But what happens when a person worries about making the "right" decision? 
Although there may be a great deal of effort to discriminate between the options, when 
reviewed over and over again, the person still cannot "psychologically discriminate" enough 



80 
to reduce the accompanying anxiety. Engaging in effortful thought might indicate central 
route processing but thought alone does not determine route of processing. The 
determination is made through the creativity and richness of the thoughts produced. In 
central route processing, effortful thought is engaged in only as long as new ideas emerge. 
Langer (1994) states that there is a two-part process: generating options and then choosing. 
Some people, however, do not generate new options and do not choose, thus making their 
effortful thought fruitless. 

This inability to choose may be explained by the Yerkes-Dodson curve (Yerkes & 
Morguiis, 1988). This theory suggests that with too little anxiety, a person is uninvolved 
and lacks the motivation to act; too much anxiety and the person lacks the ability to act. It 
is suggested in this research that some people, although a minority, will shift between a few 
options and never discriminate enough to come to a cognitive commitment to any options, 
thereby indicating peripheral route processing. For example, patients may agree under 
pressure to do something, such as enter into chemotherapy treatment, yet they internally 
experience tremendous anxiety due to equivocating about the wisdom of their decision. 

This category of decisional style is named ruminating style. Persons fitting into this 
category would express considerable worry and fear about whether their decision was 
correct in spite of having begun to act. They would remain uncertain regardless of new 
incoming information and they would continue to put forth a great deal of effort into 
thinking the same thoughts repeatedly, ignoring the new information. The ruminating style 
fits the definition of peripheral route processing because of it's continual shifting of 
opinions. Ruminating style will also be marked by high anxiety. 



81 
Rumination is an intrusive thought process that prevents a cognitive commitment to 

a decision. For example, until patients can see a clear choice that radiation is better for 
their condition and life situation than surgery, they will not feel certain with either decision. 
Rumination is differentiated from active deciding by the options generation process 
and by the flexibility of the schema involved. In active deciding, a person's information 
gathering and the ensuing association process continues only while new ideas are being 
generated. Rumination generates very few options or accepts only the few options 
presented without establishing any new associations so that new information is never 
entertained. In active deciding, once the options are felt to be exhausted, a decision is 
made and the schema that the decision rests upon is altered and allowed to remain flexible. 
Rumination becomes an impossible choice between two or a few options that are based on 
one or more rigidly-held, unadjustable schemata. 

The epistemology studies of Kruglanski and Webster, especially those dealing with 
the need for closure construct support the idea of adding rumination as a decisional style. 
Kruglanski asked the question, "How does one attain knowledge?" The construct of the 
need for closure emerged from his search to account for the inevitable differences in how 
people go about selectively absorbing and processing information. Using the same 
definition of need as Petty and Cacioppo (1986), the need for closure was defined by 
Kruglanski (1989, p. 14) as "the desire for a definite answer on some topic, any answer as 
opposed to confusion and ambiguity." In 1990, Kruglanski discriminated between a need 
for specific closure and a need for non-specific closure. 



82 

Individuals may process only a limited amount of information before making a 

decision or they may generate numerous hypotheses. They may pay careful attention to 
"on-line" details, revising their conceptions as they entertain options or they may base their 
decisions on information in memory. They may spend time elaborating on information and 
deepening their processing or they may use only the most accessible information. 

The foundation for these patterns, Kruglanski stated, was motivation. A specific 
type of epistemic motivation is the need for closure. The need for closure is both 
dispositional and situational and as such has generated considerable research seeking to 
understand the conditions under which the need for closure will be heightened or 
diminished outside the normal range for a particular individual. 

The need for closure is a continuum with people at the high end exhibiting 
impulsivity, rigidity of thought, and reluctance to consider other's views. People at the low 
end, those demonstrating a need to avoid closure, represent the group identified in the new 
model as ruminators. These are people who suspend judgement when possible, generate 
competing alternatives, and experience doubt and ambivalence. The mid range on the 
need for closure continuum would be those people who are more likely to elaborate on an 
idea arriving at a well-thought out decision. The descriptions of these categories of people 
fit both the depth of processing models and the mindfulness model. 

Certain antecedent conditions will affect a person's moving toward increased or 
decreased need for closure. Two benefits of closure are predictability and impetus for 
action and when either of these is perceived as a need, the person will be motivated to 
obtain closure on the issue in question. Time pressure increases the need for closure and 



83 
perceived effort decreases the need for closure. Using ELM'S conceptualization that 
effortful thinking is aversive to some people, the need for closure, under some 
circumstances, would be enhanced because it is simply easier than elaborating. 

In the other direction, the need for closure may be decreased in the face of fear of 
invalidity. The need for closure conflicts with the need to determine the right answer. 
Kruglanski (unpublished manuscript, p. 10) asserts, "Under heightened need for closure a 
person may generate fewer competing hypotheses and/or suppress attention to information 
inconsistent with one's hypothesis. Both may result in a sense of valid closure, uncontested 
by alternative interpretations or inconsistent evidence." Alternatively, other individuals may 
react to a heightened demand for validity by postponing closure or even avoiding it. If a 
credible source is added to the equation, the fear of invalidity may increase the tendency to 
operate on the source's advice and rather than maintaining openness and continuing to 
process centrally, a peripheral route of processing will determine the direction of the 
decision. 

In a study (Mayseless & Kruglanski, 1987, exp. 2) directing participants to operate 
a tachistoscope under conditions to either increase or decrease the need for closure, the 
extent of their information search was higher in the need to avoid closure than in the need 
for closure condition. In experiment three, participants were shown photographs of 
unusual perspectives of common items and asked to create lists of hypotheses about the 
identity of the items, and asked to then select one. To establish a need for validity 
condition, subjects were told that clear cut opinions correlated with intelligence. When 
compared with a neutral condition, participants in the need to avoid closure condition 



84 
generated more hypotheses than those in the neutral condition and, in turn, more than 

those in the need for closure condition. Similar to the studies conducted by Petty and 
Cacioppo and Langer, participants in this study and others (Webster, 1992; Kruglanski, 
Webster, & Klem, 1992; Kruglanski & Webster, 1991) exhibited more confidence in the 
need for closure condition than any of the others. 

Several studies also point to differences in the type of information sought under the 
high or low need for closure conditions. In one study (Trope & Bassok, 1983), diagnostic 
information was sought in the need to avoid closure state and more stereotypic information 
was sought in the need for closure condition. Petty and Cacioppo would view these results 
as reliance on peripheral route processing whereas Langer would see the results as mindless 
deciding. Similar to studies on these forms of processing are studies that have 
demonstrated identical priming effects (Kruglanski & Freund, 1983, exp. 1). Manipulating 
the need for closure also resulted in overestimation of conjunctive events and 
underestimation of disjunctive events in a high need for closure condition (Kruglanski & 
Freund, 1983, exp. 2). Other situations in which a high need for closure resulted in biased 
processing were correspondence bias (Webster, 1993) and overattribution bias (Webster, 
1993, exp. 2). 

This evidence supports the notion that early "seizing" and "freezing" upon 
peripheral cues and subsequent inattention to new relevant information occurs in need for 
closure conditions. This end of the continuum constitutes the individual differences in 
people who inherently possess a high need for closure. Such people also fit the description 
of mindless deciding. Evidence also supports the definition of ruminators as people with a 



85 
high need to avoid closure. These results were consistent across different manipulations of 
the need for closure as well as differentiating among people with a dispositional high or low 
need for closure. 

The need for closure construct and the research supporting it are consistent with 
both Langer's theory and the ELM. To understand decisional styles, it may be essential to 
include those people who cannot seem to make a decision as well as those who come to 
their decisions via different methods of processing. 

Methodologic Commentary 

The body of research upon which this study stands was conducted by some of the 
most highly respected social psychological researchers in the country. The number of high 
quality studies making fine discriminations between the variables under consideration were 
too numerous to cite. This review purports to give only an overview of the available data. 
Still certain concerns about methodology must be addressed. 

Generahzability must be questioned. Constraints imposed by the laboratory setting 
and the undergraduate student samples diminish the external validity of previously 
conducted research. This is particularly true for the attitude change theories and need for 
closure studies. After decades of accumulating laboratory evidence, several studies have 
been conducted on social influence theories in natural settings, but they are far too few to 
rely on with confidence. 

Eagly (1987) suggested adopting a wider range of methods to bring the 
investigation of social influence theory forward. One contribution of Ellen Langer's 
research is demonstrated in her ability to find natural occurrences to use as variable 



86 
manipulations. For example, the study investigating perceptions of elderly people having 

been raised by grandparents at different ages and that using hearing vs. non-hearing people 

to determine pre-existing schema. Because of using such naturally occurring events, it is 

possible to place greater trust in the external validity of these studies. Overall, the variety 

of ways in which these theories were tested and the consistency of the results emanating 

from several researchers' laboratories provides a strong foundation for this study. 

Cacioppo and Petty (1987) raised some doubts about the use of self-report 
measures in social influence research because of the possibility of their cognitive nature 
forcing a cognitive process that biases the results. They suggest that affect could play a 
considerably larger role than is evidenced in their studies. Cognitive scales were found to 
be more predictive with cognitive passages and less so with affective passages (Crites, 
Fabrigar, & Petty, 1994). Many of the scales used have been idiosyncratic to attitude 
about a specific item or idea leaving validity and reliability somewhat suspect. They call 
for a demonstration of consistently high reliability across objects and comparability across 
both affective and cognitive material. 

The Decisional Processing Model 

The Decisional Processing Model for medical decision-making states that patients 
will use two routes of processing, central and peripheral. It further states that the central 
route processing will include active decisional style and passive decisional style and that 
peripheral route processing will include mindless decisional style and ruminating decisional 
style. Earlier arguments on the factors influencing physical response to treatment and 



87 
coping, suggest how a person arrives at a medical decision will determine influence the 

direction of these factors. In addition to testing the existence of decisional styles, 

Decisional Styles Follow Two Routes of Processing 

Social influence theorists, focusing on persuasion, integrated the diverse literature 
on attitudes. Their discoveries, led by Richard Petty and John Cacioppo, uncovered two 
routes of processing information. The semantic differences are inconsequential. There 
exist only subtle differences in that some theories emphasize one route over another in their 
exploration. Petty and Cacioppo emphasized the central route because they were looking 
for enduring qualities of persuasion. Shelley and Chaiken (Chaiken, 1987) emphasized the 
heuristic route. Both acknowledged people's use of the alternative route. Simultaneously, 
Ellen Langer began to study the effects of decision making that seemed to occur in the 
absence of conscious thought. She coined the term mindlessness for the reactionary way 
people had of unthinkingly following cues. She also discovered what Petty and Cacioppo 
would have labeled peripheral route processing. 

Evidence has been presented in previous sections of this review suggesting a 
possible integration of not only the three social influence theories but also the theory of 
mindfulness. In a symposium on social influence, Alice Eagly (1987) closed the 
conference with a summary of the topics presented along with a review of the history of 
research in the social influence arena. She stated, "Progress (to end the confusion) might 
have been more continuous had investigators been more skilled at integrating research 
findings. The need for insightfl integration and accurate aggregation of findings has been 
particularly great for social influence research because of its early popularity" amassing 



88 



large, complex, empirical literature at an early point. It is reasonable to bring these theories 
together to support a decision-making model because not one study was found in any of 
their research that refutes the ideas incorporated in the model presented in this proposal. It 
is also reasonable to state that two routes of processing are used in making medical 
decisions among patients with life-threatening illness. 
Four Decisional Styles 

According to Langer (1994), people using active decisional styles make 
discriminations between the current event and pre-existing schema, initiate action to obtain 
information, and generate options before they decide. People using passive decisional 
styles take information as it is presented to them, think effortfully about that information, 
and then make a choice without generating new options. Petty and Cacioppo, along with 
the other social influence theorists, describe such behavior as indicative of central route 
processing. 

Other people make decisions by identifying a few simple cues, matching these cues 
with a pre-existing schemata, and arrive at a decision by making a cognitive commitment to 
that schemata. Petty and Cacioppo's (1986) research supports the idea that under certain 
conditions people process information in the way described by Langer. The term used in 
this model, taken from Langer, is mindless decisional style. It represents peripheral route 
processing. 

The research exploring the conditions under which each route of processing may be 
used has been conducted by both Langer and the social influence theorists. Findings were 
similar. The presence and availability of a pre-existing schema assists in determining which 



89 

category a person fits. All agree that central route processing requires effortful, substantive 

thought. All agree that the route of processing is affected by distractions, the amount of 
importance, and the amount of involvement, all of which limit a person's motivation and/or 
ability to process. 

Petty and Cacioppo stated that a person must make a cognitive response and 
Langer states that a decision is made when a person makes a cognitive commitment. In 
active, passive, and mindless deciding such a cognitive response (commitment) is made. 
The decisional processing model asserts that there is a fourth category in which people fit 
who do not make a cognitive commitment to any decision. Based on the evidence of Petty 
and Cacioppo, a cognitive response does not occur if either motivation or ability is absent. 
The Yerkes-Dodson theory states that when anxiety is too high, the ability to process 
information is impaired. The fourth category of decisional style includes people who are 
impaired and therefore unable to make a satisfactory decision because of their anxiety. It is 
reasonable to assume that a minority of people facing life-threatening illness would fall into 
the fourth category of the decisional processing model - ruminating decisional style. 
Some Decisional Styles Are More Effective Than Others 

Patients who take a more active role in decisions about their treatment have better 
health outcomes (Greenfield et al, 1985; 1988). Patients who have a sense of control over 
their treatment cope better (Lazarus & Folkman, 1984), report less depression 
(Meyerowitz, 1980), and use more cognitive coping strategies (Felton, Revenson, & 
Heinnchson, 1984). Decisions made actively are more likely to enhance coping than those 
made mindlessly and. 



90 
Essentially, decisions are made after discriminating between two or more options. 

This requires categorization according to a formerly processed representation (Schwarz & 
Bless, 1992; Deifenbach, Leventhal, & Leventhal, 1992). Categorization can occur either 
by contrast or assimilation. In contrasting categorization, an individual considers those 
ways in which the new object is different from the previous representation. In assimilation, 
an individual considers those ways in which the new object is similar to the previous 
representation. The danger with assimilation is that in extracting only a few aspects of the 
new situation to attend to, subtle differences are ignored. By viewing the new object as the 
same, one is more likely to respond in the same manner, thereby aborting any chance of 
ongoing adjustment. Decisional styles that do not consider all the relevant information 
deter the reappraisal process necessary to successful adaptation. 

On the other hand, an individual who categorizes by contrast, will have to create a 
new representation or adjust an old representation. These individuals are more likely to 
consider new information and think about new responses, i.e., adjust. Consideration of 
new options is elaborating on an object, detecting differences, generating hypotheses based 
on these differences, and constructing a new representation which directs behavior 
differently. This is active deciding. 

Active deciding and perhaps passive deciding lead a person to become more 
personally involved in decisions regarding their treatment and their response to both the 
illness and treatment. Greater participation in medical decision-making has been shown to 
correspond with improved health outcomes (Greenfield, Kaplan, & Ware, 1985; 1988), 



91 



psychological well-being (Fallowfield, Hall, Maguire, & Baum, 1990; Morris & Royle, 

1988), and are more satisfied with their care (Greenfield et al, 1985). 

Table 2-1 

The Decisional Processing Model 



Decisional Category 



Route of Processing 



Active Decisional Style Central Route Processing 

Passive Decisional Style Central Route Processing 

Mindless Decisional Style Peripheral Route Processing 

Ruminating Decisional Style Peripheral Route Processing 



Coping Effectiveness 

Most effective coping 
Also effective coping 
Less effective coping 
Least effective coping 



As Table 2-2 shows, this research hypothesized that those people in the active 
decisional category are likely to use more effective coping strategies than any other style 
because of their ability to differentiate between options, their consideration of how 
presented options may affect them differently than other people, and the sense of control 
and efficacy required to take such an active role in determining treatment. It was expected 
that passive deciding is equally effective in coping, although there may be differences in 
self-efficacy when compared with active deciding. Because of employing so little effort in 
making the discriminations which render perception of the diagnosis of cancer as requiring 
different ways of coping, it was also anticipated that mindless deciding would lead to the 
use of less effective coping strategies. However, it is recognized that the denial commonly 
seen in people using this style may protect them from high levels of distress, especially in 
the short term coping explored in this study. Those patients using ruminating style are 



92 
likely to report the most stress. This perception of high stress in addition to their peripheral 
route processing style may lead to the least effective coping. 

Summary 
The existence of an integrated information system between what is perceived and 
how the body functions biochemically has been demonstrated in studies on coping and 
surviving a serious illness. Perception is learned within a social context and as such is both 
culturally and individually determined. Studies have demonstrated how perceptions can be 
changed resulting in changes in coping and survival. However, very few studies exist 
investigating how these perceptions evolve into medical decisions or what effect decisional 
styles may have on coping. 

In order to study decision making and use the results to provide a direction for 
designing psychosocial medical interventions, this study integrates the ELM and the theory 
of mindfulness. A review of the empirical support for these theories revealed many 
parallels. This research evidence is used to build a new model to explain decisional styles. 

The decisional processing model states that patients use four decisional styles to 
process their decisions regarding treatment and coping. The four categories are active, 
passive, mindless, and ruminating. Active and passive decisional styles are processed 
centrally and therefore may lead to using more effective strategies. Mindless and 
ruminating decisional styles are processed peripherally and may lead to using less effective 
strategies. In spite of this commonality of the route of processing, mindless and ruminating 
styles are qualitatively opposite, one making immediate reactionary decisions; the other 
never settling on any decision. 



93 
Decisional styles can be predicted using the elaboration likelihood model of attitude 
change. Research on the constructs of this model, cognitive responding, motivation, and 
ability has led to evidence about the circumstances under which a person uses peripheral or 
central route processing. Therefore, it should predict whether the patients in the different 
decisional style categories are using central or peripheral route processing. In addition to 
this prediction, evidence from research on the ELM has also demonstrated ways in which 
route of processing can be changed. If evidence accrues that demonstrates central route 
processing produces more effective coping with a serious illness, the ELM provides the 
tools to change the route of processing information. 



CHAPTER THREE 
METHODOLOGY 

Overview 

This inquiry sought to understand how people make decisions about their life- 
threatening illnesses and how their decisional styles affect coping. Using the research 
supporting the theories of mindfulness and social influence, a decision making model was 
created. The study explored the identity of existing categories of decisional styles, how 
these decisional styles are predicted by certain variables, and how decisional styles affect 
coping. Interviews for this exploratory study were conducted with cancer patients actively 
involved in treatment. The Methodology section includes descriptions of the population, 
sample, sampling procedures, research design, data analysis, and instrumentation. 
Concluding this chapter are the limitations of this research. 

Population 

The population from which the sample for this research was drawn consists of 
cancer patients under treatment at Shands Cancer Treatment Center in Gainesville, Florida. 
The Center attracts patients from a geographic area encompassing six southern states, but 
the majority of the patients reside in Florida. The population of the State of Florida by 
race in 1996 was 84% Caucasian, 10% African-American, 13% Hispanic, and 1% other 
(Statistical Abstracts of the United States, 1996). Statistics are not kept on the racial mix 
of cancer patients served by Shands. In 1996, 1,359,150 cancer diagnoses were given 

94 



95 
nationwide. Of these, 136,380 were African-Americans, who have a higher incidence of 
cancer and higher mortality rates. This is true for other minorities as well. In 1995, 
Shands Medical Center treated 1,428 males and 1,108 females for cancer (Tumor 
Registry, Shands Medical Center, 1995). 

Shands Cancer Treatment Center provides medical services for people from a wide 
range of socio-economic levels. The Center treats patients without regard for ability to pay 
and consequently draws a significant number of Medicaid patients. The Center also 
attracts patients from a wide variety of economic levels who seek state-of-the-art diagnostic 
and treatment methods. 

Sample And Sampling Procedures 

The participants in this study were adults with a diagnosis of any unremitted cancer. 
There are two reasons for taking an inclusive approach to the diagnostic categories 
explored in this study. First, in studies on coping, findings did not differentiate between 
different types of cancer (Cassileth et al, 1984; Pollack, Christian, & Sands, 1990). 
Second, certain cancers are more prevalent in particular age groups and some are specific 
to gender. Limiting this study to certain cancers would limit the ability to generalize across 
genders and age groups. The diagnostic categories are listed in Table 3-1. 



96 



Table 3-1 

Frequencies and Types of Diagnoses of Participants 



Type of Cancer # f patients 

Lymphomas (Hodgkin's and non-Hodgkin's) 17 

Breast cancer (with and without metastasis) 3 1 

Lung cancer (adenocarcinoma, small cell, non-small cell, 

& squamous cell 16 

Cancer of the head and neck 4 

Brain cancers & metastases to the brain 3 

Gastro-urinary cancers 12 

Ovarian cancer 3 

Liver & pancreatic cancer 5 

Leukemias 6 

Multiple myeloma 3 

Vascular sarcomas 2 

Carcinoid symdrom with metastasis 1 

People with multiple distinct cancers 4 



Because cognitive ability is essential in gathering the data in this study, any patients 
with an indication of cognitive impairment, either as a symptom of their cancer or their 
physician's estimation, were excluded from participation. The ethnic composition of this 
study included 85.8% Caucasians, 10.8% African-Americans, 1.7% Hispanic, 1.7% Asian. 



97 
Three participants, willing to be in the study, had to be excluded due to their limited facility 
with the English language (one was Hispanic and two were Asian). In all three cases, the 
protocols were attempted using an interpreter, however, this proved to be too difficult to 
gather the information as accurately as the other participants in the study and the effort was 
abandoned. The gender composition consisted of 64.2% females and 35.8% males. 

Patients receiving their initial diagnosis fewer than three weeks prior to this study 
were excluded. If persons actively seek information and give careful consideration to the 
results of their search, it will take time to do so. It is impossible to know whether persons 
in this period of weighing options are ruminating or engaging in effortful thinking. After 
the occurrence of traumatic events, people often go through a period of shock lasting from 
a few hours to a few weeks (Filipp, 1992). To prevent the results being confounded by the 
shock or by not allowing enough time to discriminate, anyone having received their 
diagnosis fewer than three weeks prior to assessment were excluded from the study. 

Other demographic information about the participants included marital status and 
education level. Eighty percent of the participants were married, 3.3% divorced, 12% 
widowed, and 5.7% single. Twelve-point-six percent had less than a high school 
education, 28.6% completed high school, 33.6% attended some college or vocational 
school but did not complete, 8.4% were college graduates, and 16.8% had advanced 
degrees. The amount of participants with advanced degrees is unique for this location. 
Shands Cancer Center is considered a state of the art clinic with access to new 
experimental treatments and knowledge often unavailable in smaller centers. It is seen as a 
mecca which draws people for sophisticated treatment and difficult cases and as such is 



98 
likely to drawn a unique population of patients from a greater geographic area. As will be 

shown in the results section, the preponderance of such educated people may be the result 

of exploration on the part of the patients. In addition, it is located in a town in which the 

major employer is a university. Although the sample may be representational of regional 

cancer centers' patients when the center is situated in a university setting, it may not 

represent that patient population in cities with a lower percentage of highly educated 

people. This factor could influence prevalence rates of people in the different decisional 

styles categories. 

Medically, the patients in this study were quite sick reflecting a skewed population 
of people whose treatment may have required such sophisticated or experimental efforts. 
Often after the inability to diagnose, or ineffective treatments begun in smaller towns, 
patients are referred to a center such as Shands. As a result it is likely the sample contains 
many patients with more advanced disease. A full 51% of the patients had stage IV 
cancers; 20% had stage III; 16% had stage 2; and only 7% had stage I disease. Prognoses 
also were concentrated in the more severe range. Twenty percent had poor prognoses, 
23% were fair, 25% were guarded. One physician explained his interpretation of guarded 
is a patient who is doing well now but unlikely to live beyond six months. Thirteen percent 
were in the good range, and another 13% had very good prognoses. Sixty-four percent of 
the patients had no previous cancers; 35.6% were being treated for a recurrence/second 
cancer. 

Although in the ensuing analysis, continuous data were used, a record of the dates 
since the initial diagnosis was obtained. Eleven percent had been diagnosed less than one 



99 
month, 13% diagnosed less than three months, 26% diagnosed less than six months, 17% 

diagnosed less than one year, and 43% diagnosed over one year. However, if the 35% 

treated for recurrent disease were subtracted from this figure, only 8% had been diagnosed 

with their current cancer over one year. 

Sample size was one hundred and twenty participants. In discriminant function 
analysis, small samples are subject to bias when calculating the number of persons 
accurately categorized. Samples that are too large may result in an overestimation of the 
accuracy rate (Huberty, 1975). Huberty recommended the inclusion of three times as 
many cases in the smallest group as the number of existing variables, with an additional 
one-third to be used as a cross-validation sample. If this formula were to be used, the 
current study should include seventy subjects. 

By contrast, Kass and Tinsley (1979) recommended ten times the number of 
variables which would result in a sample of thirty for this study. Both Brown and Tinsley 
(1983) and Tatsuoka (1970) recommended that the smallest group should include no fewer 
than the number of variables used. Using this standard, no category in this study would be 
likely to result in fewer than three participants. However, by categorizing people on three 
predictor variables and four categories, thirty subjects may be too small to detect an effect 
size, especially given the exploratory nature of this study. 

A third method of calculating the sample size is by multiplying the predictor 
variables times ten for each cell and again multiplying by the number of degrees of 
freedom in the criterion variable. This study has four predictor variables: Need for 
Cognition Scale, Need for Closure Scale, Padua Inventory - Rumination Subscale and 



100 
Ability To Process Questionnaire. It includes four criterion variables: active deciding, 

passive deciding, mindless deciding, and rumination. Therefore a sample size of one 

hundred twenty participants was used. 

Sampling Procedures 

Four locations within the Shands system were used. Fifty-five participants were 
interviewed in the clinic, while waiting for their doctor. Fifty-four participants were 
interviewed while undergoing chemotherapy in the outpatient chemo room. (Those who 
experience nausea during their chemo treatments are typically given atavan. One of the 
side effects of atavan is drowsiness. Those participants treated with atavan were eliminated 
from participation.) Ten patients were interviewed while undergoing treatment in the 
hospital and one was interviewed in the bone marrow transplant unit. 

Referrals to the study were obtained through physicians, social workers, nurses, and 
physician's assistants. Patients were sometimes approached by a staff member and asked if 
they wished to participate but more often a staff member would designate which patients 
were appropriate for the study (based on criteria set) and these patients would be 
approached by a researcher. The study was explained to the staff at the regularly 
scheduled weekly conference. 

Five researchers were used to conduct the interviews. The researchers did not 
make any decisions and therefore no inter-rater analysis was required at this point. Two 
researchers, the investigator and a social worker, conducted one hundred of the interviews. 
Both of these women were licensed therapists with over fifteen years experience in 
working with cancer patients. The remaining three researchers covered the hospital 



101 
participants. They were all mental health counselors with varying levels of experience, 
none of which was with cancer patients. A two-hour training session was provided for 
each researcher covering the ideas, tasks, and requirements of the study and the interview. 
Although the researchers understood how to discriminate between decisional styles, they 
did not know the hypotheses. 

Confidentiality in this research was protected by the use of coded data packets. 
The master list linking names and codes was retained separately by the principal 
investigator in a locked file and handled in the same manner as confidentiality with therapy 
clients. It was unnecessary for any other sources to be privy to this master list. 

Research Procedures 
Potential participants who were awaiting treatment or undergoing chemotherapy 
treatment were presented with information about the study and asked if they were 
interested in hearing more. If they responded affirmatively, the consent form was provided 
and read along with the patient. If they consented to the interview, they knew that the 
interview would be interrupted when their physician entered the room. The majority of the 
clinic interviews were interrupted by medical examinations. Since Shands is a teachina 

to 

hospital, medical students and fellows often saw the patients prior to their physician. 
Seldom was it necessary for patients to remain in the clinic longer than this process in order 
to complete the interview. 

One hundred and twenty-three people agreed to be interviewed. Due to lan<nia'-*e 

to to 

barriers, three were excluded by the researcher. Eighteen patients refused to be 
participants. Six of these people offered no reason, four stated they were too emotionally 



102 
upset, and eight said they were too sick that day but would be willing another time. Two 

patients who were eligible according the study criteria were excluded by the medical staff 

because they knew they were about to hear bad news that day. All other patients who fit 

the criteria were eligible for the study. The only reason they were not included was if the 

researchers were already busy with other participants. 

The Interviews 

There were two procedural stages in this study. The first was a determination of 
which decisional style was employed by the participant in coming to decisions about their 
illness. The second stage was the administration of the standardized instruments assessing 
the predictor variables. For the first stage of assessment (determination of decisional style), 
a multi-method approach was used to assess the category of decisional style which best 
represents the participant. In one method, the participant reported his/her identification 
with a story and using another method, participants were asked specific questions about 
how they arrived at the specific medical decision related to their cancer. The former is 
referred to as the vignettes, the latter as the decision tree. 

The assumption was made that the process of deciding is relatively accessible to 
conscious awareness when attention is so directed. The interview began with a semi- 
structured interview in which the researcher asks questions which are framed by a decision 
tree leading to the four categories under scrutiny. This was followed by the researcher 
having read four vignettes describing the different decisional styles, then asking the 
participant which parable was most representational of their way of deciding about their 
illness. 






103 
The second procedural stage was a structured interview conducted by the same 
researcher at the same time and consisted of the measures of the predictor variables. This 
structured interview used the following instruments chosen for this study: 1 ) Need for 
Cognition Scale, short form (Petty, Cacioppo, & Kao, 1982), 2) Need for Closure Scale 
(Webster & Kruglanski, 1994), 3) Padua Inventory, Rumination Subscale (Sanavio, 1988), 
4) Ability to Process Questionnaire, and 5) Ways of Coping Scale (Lazarus & Folkman, 
1984). 

Although this interview had been previously timed and found to take forty minutes 
if questions were answered without embellishment, the actual interviews took 
approximately one hour to an hour and a half. A few interviews took two hours. The 
reason for the length was not a lack of understanding the question, but a high need to talk 
among this population. Participants sometimes cried, vented their emotions, asked 
questions about coping, and frequently offered in-depth details of their journey through 
their illness. Many issues came up, such as one woman who debated about leaving her 
husband since he reacted to her cancer by becoming physically abusive to her or the old 
southern gentleman who after crying through the interview told the researcher, "I am so 
glad to talk with you. I must be strong for my family and can't talk to anyone else." 

In addition to the two methods of determining decisional styles and the instruments 
assessing the predictor variables and coping, medical data was obtained from the patient's 
computerized records to determine differences based on stage, prognosis, type, date of 
diagnosis, or recurrence. Stage and prognosis, not available from computerized records, 
was determined by their attending oncologist after the patients were interviewed. 



104 
Relevant Variables and Analysis 
Types of Analyses 

Discriminant function analysis was used to test the model proposed in this research, 
Discriminant function analysis is used to predict the category into which a person will fit 
based on the predictor variables (Borg & Gall, 1989). This analysis is recommended when 
using two or more continuous independent (predictor) variables and one categorical 
(criterion) variable (Borg & Gall, 1989). Discriminant function analysis was used to assess 
the power of the predictor variables to accurately categorize the participants according to 
their decisional styles. This analysis sought to maximize the discrimination between already 
existing or defined groups by maximizing the ratio of variance between them. Discriminant 
function analysis is a statistical procedure which assigns index numbers to participants who 
have been identified as belonging to a certain category in order to determine the power of 
the predictor variables to discriminate. The basis for the initial assignment was derived 
from the characteristics of the different categories of decision-makers. 

Discriminant function analysis is designed to measure the characteristics that are 
most important in representing the categories, establish how these dimensions are 
described, and designate which variables contribute to these dimensions. The predictor 
variables are determined by theory and research and should not be correlated with each 
other. 

With the exception of need for closure, the predictor variables in this study are well 
supported throughout the research conducted on the elaboration likelihood model. The 
inclusion of need for closure is supported by the work of Kruglanski (1989, 1990, in press) 



105 
and Webster & Krugianski (1993, 1994). According to Brown and Tinsley (1983), the 

predictor variables should be restricted to a theory-driven few. By measuring participants 
on more than one variable, small group differences are weighted and added together to 
increase discrimatory power by forcing mathematical distinction (Sanathanan, 1975). 
Weights are assigned based on the magnitude of relationship differences. Intercorrelations 
are excluded. 

Continuous measures for predictor variables are needed for this analysis so that the 
discriminations are not artificially constrained to a discrete number of numerical categories 
(Carpenter, Deloria, & Morgenstein, 1984). Factors of the elaboration likelihood model 
meet this criterion. The criterion variable must be discrete. The category of decision 
making satisfy this requirement. 

A chi-square analysis was used to determine the probability of the frequency rates 
of gender, race, age, type of cancer, stage of cancer, recurrence, and prognosis occurring 
by chance. Chi-square designs are used to determine frequency probability between 
categorical variables. 

In addition to the determination of categories of decisional styles and their 
predictors, the relationship between decisional styles and coping was tested. The Ways of 
Coping Scale consists of two trigger questions and a scale of questions in which the 
participant is asked to respond to their answers to the first two questions. The first 
question, categorical in nature, were analyzed using a chi-square. Both the second 
question and the scale are continuous measures and their relationship with decisional styles 
were therefore analyzed using a one way analysis of variance. The relationship of the 



106 
individual scales to the decisional styles were tested using a one-way analysis of variance. 
The independent variables used in each analysis independently are the Need for Closure 
Scale, the Need for Cognition Scale, the Padua Inventory - Rumination Subscale, and the 
Ability to Process Questionnaire. The dependent variables are decisional styles: active 
deciding, passive deciding, mindless deciding, and ruminating. Anovas are used to 
compare three or more independent groups. 
Criterion Variable 

The criterion variable was decision making style. The categories of decisional 
styles were: 1) active deciding (mindfulness; generating options and deciding from among 
those options)., 2) passive deciding (deciding among presented options), 3) mindless 
deciding (making a premature cognitive commitment without careful thought), and 4) 
ruminating (equivocating on a few options without discriminating enough to make a 
decision). 
Active Deciding 

Active deciding is gathering information beyond that which is presented. Using this 
decisional style, people combine presented information with self-knowledge to generate 
hypotheses about their possible options. From these carefully considered options, active 
deciders choose those which they will implement. When they settle on a decision, they 
recognize changes, remain open to revising their decision, and demonstrate flexibility of 
thought. 



107 
Passive Deciding 

Passive deciding involves thinking about choices presented and actively selecting 
from among those choices. Although in this style, people engage in effortful thinking, 
they do not generate any new options which would allow them to consider 
recommendations based on self-knowledge. These people come to know the world as it is 
presented to them. 
Mindless Deciding 

Mindless deciding is making a premature cognitive commitment. In this decisional 
style, people make a decision based on either pre-conceived schemata or on peripheral cues 
(for example, authority of the doctor) without scrutinizing the information. Decisions are 
made quickly and without effortful thinking. After having arrived at a decision, the person 
is very certain of the decision and no new information is considered. It requires no 
adjustment in their preconceived schemata. 
Ruminating 

Ruminating is not being committed to any decision. In this style, people remain 
unsettled and ruminate about a few options. The time put into this kind of thinking is 
unproductive because it results in no new insights or options are being generated. There is 
a marked shifting between the same options over and over again. This type of deciding can 
occur even when a person is following the course of a decision, for instance, undergoing 
chemotherapy without feeling that it was a good decision. 



108 
Predictor Variables 

Predictor Variable 1: Need for Cognition Scale (NCS) 

Motivation is one of the factors involved in the elaboration likelihood model which 
determine whether a person is likely to put effortful thought into a message. Factors 
influencing motivation are personal relevance, involvement, personal responsility, multiple 
sources and individual need for cognition. People high in the need for cognition engage in 
effortful thinking more often than people low in need for cognition. When one's health, if 
not life, is at stake, it is reasonable to assume that the personal relevance and involvement is 
high. Whether the participant considers multiple sources or not and how much personal 
responsibility they feel will be a function of the decisional styles. It is likely that the 
participants in this study are motivated by these factors and individual differences will be a 
function of their differences on the Need for Cognition Scale. 
Predictor variable 2: Need for Closure Scale (NFC) 

Need for closure is another construct which affects how much effortful thought will 
be entertained prior to making a decision. An important motivation factor consonant with 
theories of attitude change is the need for closure (Kruglanski, Webster, & Klem, 1993). 
The authors describe the need for closure as a desire for closure rather than a deficit view 
of need. The goals of this need are predictability and a basis for action. Need for closure 
is the desire to have an answer to end confusion and ambiguity. Need for closure could be 
specific (such as the need for an answer that satisfies a particular schema) or unspecific 
(the need for any answer), each reducing ambiguity. 



109 
Motivation to process information carefully will be affected by a person's need for 
closure. Responses to a thought-listing technique demonstrated that people with high need 
for closure generated fewer discussion-relevant thoughts and more heuristic and systematic 
thoughts (Kruglanski et al., 1993). This need for closure is both dispositional and 
situational (Webster & Kruglanski, 1994). Therefore both the Need for Closure Scale 
(Webster & Kruglanski, 1994) and the Need for Cognition Scale (Petty & Cacioppo, 
1986) will be predictor variables for this study. 
Predictor Variable 3: Padua Inventory - Rumination Subscale 

Decisions are only made when a person makes a cognitive response to a presented 
message. It is either directional or neutral. Some individuals do not make a decision. 
They shift between a few impoverished choices without entertaining new information of 
settling on a course of action. Ellen Langer stated that a decision cannot be made without 
discriminating between the choices in a way that is meaningful for the person. If people 
have a need to avoid closure, it is likely they will entertain options without discriminating 
enough to arrive at a decision. Webster and Kruglanski (1994) described the need to avoid 
closure as functionally opposite the need for closure. Although they conceptualized the 
process using a cost/benefit analysis, weighing the option of deciding vs. not deciding, there 
is no evidence that participants actually evaluated whether to engage in effortful thinking or 
not. It is possible that the persons may be continuously ruminating about the choices 
because they are mindlessly reacting to the third commitment, the commitment to process, 
which Langer (1994) described. The mindlessly made commitment to process is followed 
to avoid closing on a choice when there is no way to make such discriminations. For 



110 
example, a person following a preconceived notion that if the right decision is chosen, the 
consequences will be all positive and if the wrong decision is made the consequences will 
be all negative, may be too afraid to make a choice. 

The Need for Closure Scale is designed to discriminate between those who 
demonstrate the need to avoid closure and those who need closure. In addition to the Need 
for Closure Scale, the rumination subscale of Padua Inventory (Sanavio, 1988) will be 
used to measure rumination. The rumination scale assesses both trait and symptomatic 
impairment in mental control over doubts and repetitive thinking. 
Predictor Variable 4: Ability to Process Questionnaire (APQ) (Heesacker, 1997) 

If a person is to carefully evaluate a message using central route processing, the 
individual must have the ability to do so. Ability variables according to the ELM are "those 
that affect the extent or direction of message scrutiny without the necessary intervention of 
conscious intent" (Petty & Cacioppo, 1986,p. 8). Features of the message itself, the 
receiver of the message and the context of the delivery of the message all affect ability. 
Ability does not refer to education or intellectual levels but without regards to the depth or 
complexity of the thought content, ability refers to whether it is possible for a person to 
give time and energy to thinking. 
Dependent Variable for Hypothesis Three: Coping 

Hypothesis three sought to identify the effect of the categories of deciding, (active, 
passive, mindless, ruminating) on coping. Based on the theoretical assumption that coping 
is related more closely to the way an individual perceives and reacts to the stressor than the 
nature of the stressor alone, the Ways of Coping Questionnaire- Cancer Version (Folkman, 



Ill 

Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986) was chosen for its theoretical 
consistency with the position of this investigation. Additionally, the Ways of Coping Scale 
is, by far, the most frequently used instrument for measuring coping in the behavioral 
medicine literature. The version adapted for cancer patients changed only seven questions 
and has been used in several studies, one of which included 668 cancer patients. 

Measurements and Instruments 
Criterion Variable Measures 
Decision Tree 

A decision tree was used in a semi-structured interview conducted by the 
researchers in order to determine which category participants fit. The researchers were 
trained counselors. A two hour training session was conducted for these counselors to 
teach the theoretical foundation of the decisional styles. They were instructed to gather 
enough information for someone not meeting the participant to be able to categorize them 
according to their decisional style related to their cancer. 

The decision tree discriminates between the four decisional styles based on how the 
styles are characterized and the research supporting the variables. Each item on this 
decisional tree is well-supported by research indicating factors affecting decisional styles 
and factors describing decisional style, for example, degree of certainty (Langer, 1994) and 
type and content of effortful thought (Petty & Cacioppo, 1986). The key features for the 
active deciding category are effortful thought, option generation, and flexibility of decisions 
made; passive deciding category features are effortful thought, only options presented, 
some flexibility of decisions but alterations are based only the same premise of the initial 



112 
decision (for example, if a person make their initial decision from only those options 

presented by the doctor and no others, the alteration will only be if the doctor tells them 

something is changed); mindless deciding features are no evidence of effortful thought, 

responding to cues, decisions made fast, a high degree of certainty, and new information is 

denied or rejected; the key features of the ruminating style are a high degree of thought 

about a paucity of ideas beyond the point in which new information or ideas are 

entertained, either no decision arrived at or if a decision has been made, no commitment is 

made to it, frequent worrying. 

Questions focus on seven topic areas pertinent to making a discrimination. These 
topic areas are: amount of information presented initially, evidence of effortful thought, 
whether a decision was made or not, generation of options beyond those presented, 
responses to cues, certainty of the decision, and flexibility to change the decisions. The 
topic areas for the questions were drawn from the research-supported constructs from 
Langers mindfulness theoiy (1989) and Petty and Cacioppo's ELM (1986). By using 
topics which enjoy strong empirical support, construct validity is established. 

The format was developed according to two sources. The initial question about 
what decision were made and which were most serious is based on the format used in 
Dunkel-Schetter, Lazarus and Folkman's Ways of Coping Scale - Cancer Version (1992). 
In this scale trigger events were used for the follow-up questions that were representational 
of events occurring in the person's life. The identical format is used in this study. A list of 
choices/decisions typically faced by cancer patients are presented in order to use as a 
trigger to orient their answers based on a decision they actually faced. 



113 
The second source used to develop the format was a decision tree explicated by 

Heesacker (1993) to integrate two theories during a counseling session. Although the 

complexity used in this example is greater than that demanded by this study, it exemplifies 

the flow of questioning between several theories. 

The principal investigator then read each protocol and made a determination of 
which category the person fit according to the information provided on this decision tree. 
Inter-rater reliability was established by assigning a random sample of twenty protocols to 
two judges. These judges were experienced counselors who were not involved in any 
other aspects of the study. They were each trained in the differences between decisional 
style categories, then took the protocols home to make their assessments. 
Vignettes 

A second assessment of which decisional style a participant fits was conducted by 
having the researcher read four vignettes describing a person's decision-making process in 
making cancer-related decisions. The researcher read the vignette while the participant 
followed along reading a copy. Male names are used for male participants and female 
names are used for female participants. In every other way the vignettes are identical. 
When finished, the researcher asked the participant which vignette character is most like 
them. Their answer determined the category. 

Construct validity was determined in two ways: first, the constructs assessed were 
ones that have been grounded in the theories utilized and well supported in research 
devoted to those theories, and second, convergent validity was determined by comparisons 
of the two measures, vignettes and decision tree, which are theoretically purported to 



114 
measure the same construct. There were thirteen protocols in which the investigator 

decision of category and the participant decision of category were discrepant. In addition 

to the twenty protocols used in the reliability study, these thirteen were given to two 

additional counselor judges to obtain as accurate an assessment of category as possible. A 

Kappa-coefficient was used to determine inter-rater reliability. 

Predictor Variable Measures 

Need for Cognition Scale (NCS)- short form. (Petty, Cacioppo, & Kao, 1982) 

The need for cognition also affects a person's motivation to think carefully about a 
message. Initially, the need for cognition was described by Petty and Cacioppo (1986) as 
an intrinsic drive to use effortful thought to reduce the ensuing tension from that drive. 
Petty and Cacioppo embraced a modification of this definition and view need for cognition 
as an individual's intrinsic enjoyment of engaging in effortful thought. People with a high 
need for cognition will naturally gravitate toward more central route processing than those 
with a low need for cognition. The Need for Cognition Scale (Petty & Cacioppo, 1986) 
was developed to discriminate between people with an intrinsic motivation to engage in 
thoughtful consideration of messages and those intrinsically motivated to avoid effortful 
thinking. The Need for Cognition Scale -short form (Petty, Cacioppo, & Kao, 1984) will 
be used to measure intrinsic motivation. 

The Need for Cognition Scale was developed by Petty and Cacioppo in response 
to the need to assess the variance generated as a result of individual differences in people's 
enjoyment of effortful thinking. People who enjoyed thinking increased the likelihood of 



115 
engaging in effortful thought without consideration of factors involving message 
presentation. This intrinsic motivation is a stable individual characteristic. 

Petty and Cacioppo distinguished the need for cognition as a response style 
different from a mere avoidance of ambiguity (need for closure), which could be satisfied 
by employing heuristics or authoritative consultation. Need for closure is only one 
variable affecting a person's willingness to think about an issue. The authors of the ELM 
also differentiate need for cognition from self-efficacy since efficacy is a factor in physical 
as well as cognitive pursuits. The construct of need for cognition is further described as 
intrinsic enjoyment rather than a tension-reducing need. 

In their efforts to construct an instrument to assess need for cognition, Petty and 
Cacioppo chose questions that "excluded dealing with inner brooding, reverie, mystical or 
religious experience, mind wandering, and artistic imaginings" (p. 49). They included 
items "describing a variety of situations in which people could choose to gamer 
information, analyze available evidence, abstract from the past experiences, or synthesize 
ideas" (p.49). 

Construct validity was established in several ways: first, by the known groups 
method using university faculty and assembly line workers, and second, by university 
students, a more homogeneous population. Both samples correlated highly in factor 
loadings (r = .72). To simplify administration, a short form was then developed (Petty, 
Cacioppo, & Kao, 1984) possessing the same factor structure and correlating highly 
(r=.98) with the longer version. Internal consistency and additional support for the stability 
of the factor loadings was provided by three studies with undergraduates (Chaiken, 1986) 



116 
and one study with residents in a small town (Furguson, Chung, & Weigold, 1985). The 
last study produced a Cronbach's alpha of .86. Internal consistency was reported at .91 by 
Heesacker (1985). No gender differences were found in any of these studies. Reading 
level was appropriate for adults in various professions and educational backgrounds 
(Heesacker, 1985). 

Validation of the cognition construct was determined with the presentation of a 
boring two level task to 3500 students; one level was simple to perform and the other level 
was complex to perform. The NCS effectively discriminated between those students who 
preferred the complex task over the simple task. In assessing variant and discriminant 
validity, the following correlations were found: 

TABLE 3-2 

Construct Correlations for the Need for Cognition Scale 

Related Measures Correlations p value 

Field dependence r = . 1 9 p<05 

Close-mindedness r = -.27 and r = -.23 p< 05 

Sarason's measure of test anxiety r = .02 (ns) 

Social desirability r = .08 (ns) r = .21, p<.05 

Measures of curiosity r = .57 (Olson, Camp, & Fuller, 1984) 



117 
Need for Closure Scale: (Webster & Kruglanski, 1994) 

A forty-two item questionnaire was formulated representing five theoretical subsets: 
need for order, need for structure, discomfort with ambiguity, desire for predictability, and 
close-mindedness. The forty-two items are responded to by the subjects indicating the 
extent to which they endorse each item on a 6-point Likert scale. Sixteen of the items were 
designed to assess the respondents' need to avoid closure and are reverse scored. These 
items were negatively correlated with those on the need for closure subset (r= -.4566, p 
<01). The composite score is determined by summation of all the items after the reverse 
scoring is completed. 

The NFCS was administered to two standardization samples. The first group 
consisted of 281 undergraduates and the second was comprised of 179 adults recruited 
from three public libraries. The relatively equivalent gender groups resulted in no 
significant differences found for males and females. 

On the student population, after modifying the scale for internal consistency, a 
Cronbach's alpha = .8405 was calculated. The range for subsets were .62 to .82. Test- 
retest reliability (12-13 weeks after initial testing) was .861 1. No significant differences 
were found in the results for group two, Cronbach's alpha = .8413. The authors concluded 
that the NFCS reliably assesses the need for closure construct and is a relatively stable 
construct. 

In further testing, the authors conducted known groups tests and found that the 
Need for Closure Scale did indeed discriminate between people high vs. low in need for 
closure and in another test for primacy effects in impression formation. Those scoring high 



in need for closure did rely on primacy effects significantly more often than those scoring 
low. Correlations were conducted comparing the Need for Closure Scale with other scales. 
The following table lists the correlations conducted on the NFCS and several other scales 
sharing some theoretical characteristics. 



TABLE 3-2 Construct Correlations for the Need for Closure Scale 



Authoritarianism: Sanford, Adorno, Frenkel-Brunswik, & Levenson, 1950) r = .27 
Intolerance of Ambiguity Scale: Eysenck, 1954 r = .36 

The Dogmatism Scale: Rokeach, 1960 r = .29 

The Modified Bieri REP Test: Kelly, 1955 r = -.30 

Personal Need for Structure Scale: Neuberg & Newsom, 1993 r = .24 

Fear of Invalidity Scale:Thompson, Naccarato, Parker, & Moscowitz, 1993 r = -.39 
Need for Cognition Scale: Cacioppo & Petty, 1982 r = -.29 

QT (measure of intelligence): Amnions & Ammons, 1962 r = -.17 

Crowne-Marlowe Social Desirability Scale no correlation 



Padua Inventory: Rumination Subscale (Sanavio, 1988) 

The Padua Inventory was constructed to improve on previously developed 
measures of obsessions and compulsions. Previously constructed questionnaires focused 
on behavior traits, not symptoms, (Maudsley Obsessional-Compulsive Questionnaire, 
Hodgson and Rachman, 1977; the Self-Rating Obsessional Scale, Sandler and Hazari, 
1960) and rarely distinguished differences among normal people. Although there is a high 
incidence of obsessional rumination and intrusive cognition among obsessive-compulsive 



119 
people, the instrument measuring this important feature used only two questions to assess 
rumination. The Padua remedies these above problems by assessing symptoms as well as 
traits and distinguishing these behaviors among normal people. It also contains a subscale 
solely to assess rumination (Sanavio, 1988). 

The statements to which the tester replies were taken from an analysis of twenty- 
eight patients who were diagnosed with obsessive-compulsive disorder according to the 
DSM-III. The next step in its development was to test its ability to discriminate between 
obsessive-compulsive, depressed, and psychosomatic patients. Those statements most 
discriminatory were then given to 1,200 normal subjects. A subsequent item analysis left 
60 items rated on a 0-4 scale with the higher numbers indicating the most disturbed. The 
initial sample and several follow-up samples of the general population (aged 16-70 and 
students) were conducted in Northern Italy. Sternberger and Burns (1990) conducted a 
study on the Padua with an American population of 701 students. There were no 
significant differences between gender on the scores; race was never measured. On the 
total scores, the males and females in the youngest two age groups (16-25) in the Italian 
sample scored significantly higher than their American counterparts. 

Internal consistency for the total PI was .94. Factor loadings resulted in five 
subscales. Factor 1, "impaired control over mental activities," is the rumination subscale of 
interest for the current study. The twenty items it contains accounted for 23.6% of the 
variance. The most representative for this study is an item stating, "I find it difficult to 
make decisions even about unimportant matters." Cronbach's alpha was .89 and the 
average corrected item-total correlation was -.53. 



120 
Convergent validity was established by correlating the PI with the Maudsley 

Obsessional-Compulsive Questionnaire ( r = .68, p<.001) and the Symptoms Checklist 90, 

obsessive-compulsive subscale (r = .66, p< 001) (Sternberger, 1990). Test-retest reliability 

was .78 for males and .83 for females at a 30-day interval (Sanavio, 1988). 

Ability to Process Questionnaire, (Heesacker, 1997) 

The Ability to Process Questionnaire directly asks questions of the respondent 
about his/her ability to process the information. Each question is derived from research on 
variables affecting ability to process information centrally. It is the body of research on 
social influence which provides the construct validity of this questionnaire. Questions 
asked refer to the literature on external and internal distractions (Petty & Brock, 1981), 
time (Fazio, 1993), involvement (Johnson & Eagly, 1989; Petty & Cacioppo, 1979, 1984, 
1990), anxiety or worry (Smith & Petty, 1995) and a straightforward question on whether 
the participant perceived that he/she was able to think about the topic. 

This questionnaire follows the precedented format of referring the participant to an 
actual decision made by asking these questions in response to the decision named by the 
participant early in the interview as the most difficult to make related to his/her cancer. 
Circumstances will significantly vary a person's ability to process information. The reason 
a referent point is used to trigger thinking about a certain question because ability to 
process is not a stable condition across situations, but relevant only to the situation under 
question. 

Reliability of this instrument follows the same rationale of the coping instruments 
used in this study. Lazarus and Folkman's theory delineates a process in which people 



121 
adapt to the stressors in their lives as a stressor moves from being acute to being chronic. 

The coping scale developed to measure this process assesses the strategies utilized at the 

moment of testing and not necessarily that used over time or in different situations. 

Although this approach has been criticized, their coping scale is one of the most used in the 

research on coping with medical illness. 

Use of this method is justified by it's theoretical consistency with both the Lazarus 
and Folkman (1984) perspective on coping, and the theoretical postulates of the ELM. 
The rationale is also supported by the face validity that suggests how one may cope with 
cancer is not necessarily static over the course of treatment, nor how the same person may 
cope with another stressor. 
Dependent Variable 
Ways of Coping Questionnaire, (Folkman & Lazarus, 1988) 

The rationale providing the foundation for the Ways of Coping Scale is the belief 
that psychological distress is related more to the way people cope than the type of stressor 
involved. A strategy used to cope with one event may not be ideal for another event. The 
Ways of Coping Questionnaire provides theoretical consistency with the proposed 
research. Both this questionnaire and this study construe the process (decision making or 
coping) as a dynamic process involving the person, other people and situations in their 
environment, and individual differences. The questions refer the test taker to think about a 
particular stressor. 

Because of the situation specific nature of the questions, the authors felt that 
traditional test-retest reliability is inappropriate and focused on internal consistency. The 



122 
scales range from .61 to .79 Cronbach's alpha. The original structure analysis resulted in 
eight factors that were well supported in the population (middle and upper middle-class, 
married people) assessed but the findings in studies with other populations raise some 
concerns about factor stability. Stability across time using mean autocorrelation was quite 
low (.25 to .47). After reporting their results in traditional test construction criteria, the 
authors disavow the likelihood that a questionnaire representing "an evolving strategy" 
could be held to such standards. 

The questionnaire was originally developed in 1977 and in spite of these criticisms, 
has been through several stages of refinement with the current version having been 
published in 1988. It has been used in a multitude of studies pertaining to adjustment to 
illness and was created on the solid research program of Richard Lazarus. 
Ways of Coping - Cancer Version (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & 
Gruen, 1986) 

A form of the WOC was created specifically for research on coping with cancer. 
The authors felt that since the original WOC was designed to assess adaptation over 
repeated assessments, administering the questionnaire once would reflect an 
unrepresentation and inaccurate example of coping for that participant. The instrument is 
designed to measure response to a particular stressor. The authors identified specific 
cancer-related stressors from previous studies (Dunkel-Schetter, 1982; Revenson & Felton, 
1985). These are fear of future recurrences, limitations, pain and symptoms, and 
interpersonal problems related to peoples' reactions to the illness. Respondents choose 



123 
whichever ones they find most stressful from a list and assign a valence of 1 to 5(extremely 
stressful) to each item they mark as relevant. 

Six items from the original scale were dropped because of non-applicability to 
cancer diagnosis. Four items which did not load onto the eight factors in the revised 
instrument were included because of their determined relevance to cancer. A few items 
were reworded slightly and a few items were added to comply with additional coping 
behaviors observed in cancer patients (Dunkel-Schetter, 1982). 
Medical Data Form (MDF) 

A medical data form was constructed from the patient's computerized medical 
information to assess factors which could affect differences. Recurrence (Malcarne, 
Compas, Epping-Jordan, Howell, 1995; Dean & Surtees, 1989; Hilton, 1989, marital 
status (Dahlquist, Czyzewski, & Jones, 1996; Yates, Bensley, Lalonde, & Lewis, 1995), 
and age ( Jacobsen & Butler), have been shown to affect coping. It is not known how these 
factors affect decision-making. It is reasonable to believe that a person experiencing a 
recurrence of cancer will be more knowledgeable than a person with a first time diagnosis. 
It is also anticipated that a person facing a Stage IV cancer with very little chance of 
survival may react very differently than the person with a Stage II curable cancer. 
Participant's cancer history will be collected from their medical charts. 

Another feature of the disease that may prevent participation is diminished 
cognitive functioning. Some cancers (Pavol, Meyers, Rexen, & Valentine, 1995; Meyers 
& Albruzzese, 1992) affect cognition and may influence a person's ability to gather 
relevant data. Participants whose charts reveal cognitive deficits will not be included in the 



124 
study. Although length of time since the diagnosis has been shown to have little effect on 
coping (Dunkel-Schetter, Feinstein, Taylor & Falke, 1992), it does take time to gather 
information and make a thoughtful decision. In order to discriminate between those people 
putting active effort into hypothesis testing from those who are ruminating, a sufficient 
amount of time since the diagnosis must have passed for the active deciders to have 
finished their exploration. Therefore the amount of time since the diagnosis will be 
assessed. 

TABLE 3-3 

Predictor and Criteria Variables for Hypothesis One: 
PREDICTOR VARIABLES CRITERION VARIABLE: 

Need for Cognition Scale DECISIONAL STYLE 

Need for Closure Scale Types: 

Padua Inventory- - Rumination Subscale Active Deciding 

Ability to Process Questionnaire Passive Deciding 

Mindless Deciding 
Ruminating 

Hypotheses 

1. Participants will both self-select and be selected by the discriminant function analysis 
placement into the four decisional styles. 

2. H: NFC, NCS, Padua, and Ability to Process will significantly predict decisional style. 

3 . H: A>P>M=R on Ways of Coping Ho: A>P>M=R on Ways of Coping 



125 

4. H: A>P>M=R on Need for Cognition Ho: A=P=M=R on Need for Cognition 

5. H:M>R=A>P on Need for Closure Ho: M=R=A=P on Need for Closure 

6. H:R>A=P>M on Padua Inventory Ho: R=A=P=M on Padua Inventory 

7. H:A=P>R>M on Ability Questionaire Ho: A=P=R=M on Ability Questionnaire 

Data Analyses 

The first hypothesis tests whether people actually use different decisional styles in 
making medical decisions. Both the decision tree (information gathered from the semi- 
structured interview) and the vignettes (the patient's choice of which pattern of decision fit 
their style) were used to determine if patients did exhibit significantly different patterns of 
decisional styles. A determination was made by the investigator about which category a 
person fits. Two professional counselors reviewed twenty protocols and chose a category. 
Inter-judge reliability was assessed. 

The second hypothesis tests the theoretical model proposed in this research. The 
criterion variables categorize people according to the decisional style they used in making 
an important medical decision when confronted with a life-threatening illness. Differences 
on the predictor measures were determined by employing a discriminant function analysis. 
One purpose of discriminant function analysis is to classify individuals into predetermined 
categories (Nordlund & Nagel, 1991; Tatsuoka, 1988). The predetermined categories in 
this study were selected through the multi-method semi-structured interview. After 
identifying each individual's decisional style, the discriminant function analysis tested the 
predictive ability of the measures entered: Need for Cognition, Need for Closure, Padua 
Inventory, and question about opportunity to elaborate. 



126 



TABLE 3-4 

Hypothesis Three: Decisional Styles and Coping 



H5: ul> u2 & u3 & u4 
u2 > u3 & u4 
u3 = u4 

H5o: ul = u2 = u3 = u4 



Hypothesis three exploring how decisional styles are related to coping were 
analyzed using a one-way between subjects ANOVA for unequal cells. The independent 
variable was decisional style with four levels and the dependent variable was the Ways of 
Coping Scale. Assignment to the groups (four levels of decisional style) was determined 
by the participants' responses to the multi-method, semi-structured interview and compared 
on the mean scores on coping scale. Significance will be set at alpha = .05. 

Because the cells were unequal, there was a possibility that the assumption of 
homogeneity may be violated. The F maximum test was performed to test for homogeneity 
of variance (Shavelson, 1988). 

Hypotheses four through seven were analyzed using a one-way analysis of variance 
for unequal cells. The independent variables were, respectively, Need for Closure, Need 
for Cognition, Padua Inventory - Rumination Subscale, and Ability to Process 
Questionnaire. Each variable was entered independently into an anova calculation with the 



127 
dependent variable decisional style. Decisional style has four qualitatively different levels, 
active, passive, mindless, and ruminating. Significance level was set at alpha = .05. 

Because the cells were unequal, there was a possibility of the assumption of 
homogeneity being violated (Shavelson, 1988). To be more confident in the results an F- 
test Maximum was performed. If the F statistic were too high, it would be an indicator that 
it is not a homogeneous sample and the data will be transformed through taking the 
logarithm of the scores (Winer, 1971). 

In order to determine whether there were differences in decisional styles based on 
descriptive data, the following variables: gender, race, age, stage of illness, and prognosis 
were tested across the four categories of decision-makers using a chi-square analysis. This 
statistical test is used when the research data are in the form of frequency counts. Chi 
square analysis is used with categorical data to determine whether frequency distributions 
differ between groups (Borg & Gall, 1989). Such non-parametric tests are used to 
determine distribution among categories. Both the dependent variables: demographic data 
and the independent variables, decision-making categories are discrete categorical variables. 
The accuracy of the chi-square statistic is dependent upon each category containing no 
fewer than ten participants (Shavelson, 1988). Although it was theoretically consistent to 
believe that these criteria will be met, the ruminator category held only four participants. 

Limitations 
Generalizability limitations 

While the sample was drawn from only Shands Cancer Treatment Center, the 
Center does attract patients from the entire Southeastern United States and is committed to 



128 
serving low income patients as well as those choosing Shands for its diagnostic and 

treatment expertise. The breadth of its patient population allows the findings of this study 

to be generalized to other cancer patients with relative certainty that the sample described is 

representational. 

There is conflicting evidence in the research whether social and psychological 
processes can be compared across diseases. Factors such as age of onset, course of illness 
(chronic, acute, remitting), level of disability, and prognosis, and treatment complexity have 
been shown to affect the impact of an illness (Holland, 1987). In contrast, several studies 
support the notion that impact and coping do not vary significantly across diseases (Pollack 
et al, 1990; Cassileth et al, 1984). Application of the results of this study to diseases other 
than cancer must be viewed with caution. 

A possible sampling bias does exist in the elimination of people with cognitive 
impairment. However, when one considers that people in this condition often have their 
medical decisions made by family members, it would create a graver error to include them 
in the study. This discrimination makes the sample a non-random sample. Another 
sampling bias occured with the education level of the participants. This study included an 
overabundance of people with advanced degrees when compared to a cross-section of 
American citizens. 

Another possible source of sampling error is the solicitation of participants from a 
regional cancer center rather than several regional cancer centers. Information regarding 
these differences are not possible to obtain because Shands does not keep statistics on these 
factors. 



129 
A source of sampling bias not controllable is that of using volunteers. Patients may 
choose not to volunteer on the basis of a personal or social reason, but they also may 
choose not to volunteer because they are too sick to engage in the interview. Certainly, 
some people were too sick to engage in an interview; these people may use very different 
strategies in their decision-making. Investigation of this factor is beyond the scope of this 
study. 

It has been demonstrated in both the research of Langer (Langer, Blank, & 
Chanowicz, 1978) and that of Petty and Cacioppo that intellect has a negligible if any 
effect on the variables considered in this study. Additionally, it has been demonstrated that 
differences in coping are unrelated to socio-economic level and education. Information 
was collected on education level but not on socio-economic level. 
Limitations in assessment 

This study includes self-report assessments and therefore is susceptible to 
respondent bias. The Padua Inventory contains a lie scale which will be considered in the 
analysis. In addition, every effort was made in the research design to account for such 
bias. Multi-methods is the use of various means to measure the same trait and is a 
recommended means of establishing construct validity (Heppner, Kivlighan, & Wampold, 
1992). By using both the semi-structured interview and self-report instruments, this study 
employed a multi-method design. Multi-trait refers to various characteristics of people. 
Some of the constructs measured in this study are assessed using instruments which tap 
different traits related to the same construct. For example, motivation was assessed by 
measuring both need for cognition and need for closure. Both have been shown to 



130 
influence motivation (Petty & Cacioppo, 1986; Kruglanski & Webster, 1996), yet have low 

correlation (r= -.283 1) demonstrating that they indeed are measuring different traits 

involved in the construct motivation (Webster & Kruglanski, 1994). 

The relationship between coping and decisional styles studied was the strategies 
used for coping since there is significant literature linking certain coping strategies with 
long-term physical outcomes. The degree of stress was assessed as an ancillary item with 
just one question. The chances of denial (a prevalent defense used among cancer patients) 
influencing how a person answered this question is quite high, especially when one 
considers the majority of patients in this study have less than one year to live, yet many 
stated that having cancer was "somewhat stressful". The dimension of denial and the 
degree of stress was not sufficiently measured in this study due to the length of the 
protocols. 
Limitations in analysis 

One limitation of discriminant function analysis occurs when the predictor variables 
correlate highly with each other. The first predictor entered will reflect a high discriminant 
function coefficient even if the predictors are fairly equal in their predictive capability 
(Borg & Gall, 1989). To identify if this problem is occurring in this study, correlations 
between the predictor variables were computed. Another possible analysis limitation is 
imposed by having unequal cells in the Anovas. This limitation, however, was addressed 
by performing an F test and consequent transformation if indicated. 



131 
Theoretical Limitations 

An abundance of research literature exists on the role of emotion in decision- 
making, coping, and the ELM constructs. This study did not consider the role of emotion 
because to do so would have been unwieldy both in the design of the research and in the 
length of the interviews. If emotions were also considered, it is unlikely that the categories 
would be any different but their relationship to the other variables may have been different. 
Investigation of how emotion influences decisional styles requires further investigation. 

Even with the hypotheses supported, far more investigation between decisional 
styles and coping needs to be conducted before these results could be ethically included in 
a psycho-educational program. 



CHAPTER FOUR 
RESULTS OF THE STUDY 

The purpose of this study was to explore how people facing a life-threatening 

illness make critical decisions about their medical treatment and how their decision making 

style affects coping. A research-supported model was created and tested for its viability. 

Specifically, this study attempted to answer for the following questions: 

1) Do patients use different decisional styles when making medical decisions? 

2) Do the variables of motivation, ability, and cognitive responding, delineated by 
the elaboration likelihood model, together with a measure of rumination, predict 
decisional style? 

3) Do these decisional styles influence how effectively patients cope with a life- 
threatening illness? 

Results of this study are presented in five sections. The first section will address 
Hypothesis 1, along with some descriptive information about patients within the decisional 
style categories. This section also includes reliability data on the determination of 
decisional categories. The second section will address Hypothesis 2, the discriminant 
function analysis assessing the ability of the four variables to predict participants' decisional 
category membership. The third section addresses the third hypothesis, the relationship 
between coping and decisional style. Section four includes the analyses for hypotheses 4 
through 7, which explore the relationship between decisional styles and each of the four 

132 



133 
predictor variables independently - Need for Closure, Need for Cognition, Ability to 

Process, and Padua Inventory - Rumination Subscale. Section five covers the ancillary 

analyses and conclusions. 

Decisional Categories 

Hypothesis One: 

Hypothesis 1, that people demonstrate four distinct decisional styles in making 
medical decisions was supported by every measure. The investigator's category, which was 
a composite between the decision tree and the reasons for the patient's choice given on the 
vignettes was the variable used in the subsequent analyses. Active decisional style was 
used by 32.5% of the participants to decide medical treatment of their cancers. Passive 
decisional style was used by 22.5% of the participants. The largest category was the 
mindless decisional style, which included 41.7% of the patients. Only 3.3% of the patients 
used the ruminator decisional style. 

The patients, themselves, selected their category of decisional style by identifying a 
vignette that was most like them. Twenty-seven point seven percent of the patients chose 
active decisional style, 18.5% chose passive decisional style, 49.6% chose mindless 
decisional style, and only 3.4% chose ruminator style. 

The decisional tree was a determination made by the investigator based on the 
semi-structured interviews in which patients were asked about how they actually made the 
medical decision related to their illness. The percentage of active decisional style was 
33.3%, passive decisional style was 21.7%, mindless decisional style was 41.7%, and 



134 
ruminating style was 3.3%. Table 4-1 contains the proportions of participants in each 
decisional style category. 



Table 4-1 

Percentage of Participants in each Decisional Style Category 



Decisional Category Vignette Decision Tree Final Investigator 

Choice 
Active decisional style 27.7 33.3 32.5 

Passive decisional style 18.5 21.7 22.5 

Mindless decisional style 49.6 41.7 41.7 

Ruminating decisional style 3.4 



"5 --> 
J.J 



Comparisons were made between these different methods of placing a person in a 
decisional style category using a chi-square. Vignettes and decision tree interview 
comparison resulted in a significant chi-square statistic of x2 (12, N~ 119)= 193.36, 
p<.000\ . Comparison of the decision tree and the investigator category was chi-square x2 
(9, N= 120) = 338.48, jCK.0001. Vignettes and investigator category resulted in a chi- 
square x2 (12, N= 119) = 200.36, /K.0001. Inspection of the cells suggests significant 
consistency between the three methods in identifying the three decisional styles. 
Decisional Category Reliability 

Any study investigating the function of different categories of decisional styles is 
only as strong as the methods used to determine those decisional categories. This study 
employed both multiple methods of assessment and an inter-rater reliability study to 



135 
support the accuracy of the category determination for each participant. The inter-rater 
reliability study was conducted using two experienced judges. These judges were both 
experienced counselors. Neither of the judges were used for any other part of the study 
and they were blind to the hypotheses. Each judge was individually trained about the 
categories and how to discriminate between them. Inter-rater agreement for the choice of 
category was established if two of three raters (the investigator and the two judges) agreed 
on a category. 

The reliability study was conducted on twenty protocols out of a total of 120, with 
all four decisional styles included. These protocols were randomly selected and given to 
two judges to independently identify the decisional style participants most closely fit. 
Correspondence between Judge 1 and the investigator was 100% on patient category; 
correspondence with Judge 2 was 75%. Correspondence between the two judges was also 
75%. 

A chi-square was also conducted on the degree of agreement between the patient's 
choice of self-descriptive vignettes and the categorization of the participants via the 
decision tree interview. A chi square of x2 (12, JvM 19) = 200.36, p <0Q01 revealed 
significant agreement. Somewhat higher agreement occurred between the investigator's 
determination on the decision tree and the final category in which a participant was placed 
was even closer x2 (9, N= 120) = 338.47, p < .0001. 

Patients identified which category best described them through identification with 
vignettes describing the four decisional styles. The investigator determined which category 
the patient fit through the results of the semi-structured interview on the decision tree. The 



136 
two methods matched m categorizing 103 of the 120 patients. A 2 x 2 contingency 

analysis was performed comparing the two assessment methods, resulting in a significant 
effect x2 (12, N= 119) = 103.36, p < Q001). This agreement between the investigator, the 
judges, and the patients suggest that the patients were well aware of their own decision- 
making process. 
Location effects 

In order to determine whether the location of the interview was related to 
participant decision-making style, a chi square analysis was performed between decision- 
making style and the location. Conventional wisdom suggests that chemotherapy is such an 
aversive experience that interviewing participants during chemotherapy may influence their 
ability to answer the questions accurately. In this study a few people were indeed sick from 
their treatment and were usually given atavan, thus excluding them from the study. The 
majority of the people interviewed in the chemotherapy room were undergoing an IV drip 
and welcomed the distraction and conversation. Patients were even asking, "When will you 
get to me?" when they observed the researcher interviewing other patients. The 
participants appeared eager and able. 

Because this study was conducted in a teaching facility, where patients typically are 
seen by three levels of physicians, physicians in training, and, sometimes, a physician's 
assistant, there is often a period of waiting between visitations. In addition, the patients are 
often waiting for the results of CT scans and blood counts before the physician can 
determine their progress. Many of the participants, therefore, had considerable time during 
which they could be interviewed without intrusion. The interviews in clinic, however, were 



137 
almost always interrupted by the physician visits. A few people were required to remain 
later than their normally scheduled visits, in order to complete the interview, and several 
others could not stay and never completed their protocols. These incomplete protocols 
were dropped from the study. 

The hospital people were the sickest. They were hospitalized either because of a 
need for stronger, more toxic chemotherapy, a bone marrow transplant, or adverse 
reactions to treatment. Many were excluded from this study because they were too sick or 
too drugged. The few that were interviewed seemed to welcome the companionship the 
interview offered. 

In spite of the differences in the interviewing process, no significant differences 
were found related to the locations in which these interviews were conducted x2 (6, N= 
120) = 12. 15, /X.059). However, .059 is close enough to significance to warrant a closer 
look at the data. 
Table 4-2 
Differences in decisional styles based on location of the interview 





Clinic 


Chemo 


room 


Hospital 


Active deciding 


22 


15 




2 


Passive deciding 


13 


14 







Mindless deciding 


17 


24 




9 


Ruminating 


3 


1 








138 
According to the table of results, the majority of people in the hospital were mindlessly 
deciding their medical treatment choices. It is important to recall that questioning about 
their decisional style was retroactive and questioned their decision making prior to their 
hospitalization, which was often months or weeks earlier. Whether the mindless decisional 
style was an artifact resulting from being in the hospital or whether mindless deciding 
affected the patient's physical state in such a way that they were more likely to be in a 
hospital is unknown from this data. 
Researcher Effects 

Yet another way to examine these data is to determine differences based on 
researchers. The majority of protocols were completed by two researchers, one covering 
the chemotherapy room and the other covering the clinic. Three other researchers shared 
the task of interviewing in the hospital. When comparisons were made between 
researchers on every variable in the study, none reached statistical significance except those 
related to location. Because were no significant main effects for location either, it was 
decided to explore the interactive effects of researcher x location x decisional style. 
Significant differences were found x2 (4, N= 120) = 1 12.46, /K. 0001). To increase the 
cell size in this analysis, data from the last three researchers were combined. Because 
researchers were assigned to cover different locations and no other researcher effects were 
significant, results may reflect this assignment. This may indicate that the trend in location 
effect indicates that hospitalized people were more likely to use mindless decisional style, 
not necessarily a confounding effect of researcher differences. Table 4-3 demonstrates the 
researcher coverage of the location of the interviews. 



Table 4-3 



Researcher coverage of interviews 



139 



Number of interviews 



Investigator 


55 


Researcher #1 


48 


Researcher #2 


8 


Researcher #3 


7 


Researcher #4 


2 



Location of interviews 



clinic 



chemo 

hospital 

clinic & 1 hospital 

hospital 



In summary, between these explanations and the reliability studies conducted on 
categorizing the data into decisional categories, it is fairly safe to assume a high degree of 
accuracy in the decision categories used in the inferential analyses that follow. 
Ancillary Analyses Related to Decisional Style Categories 

Personal characteristics effects. Two personal variables that correlated with 
decisional style were age and education. Education was one of the personal variables 
which reached significance x2 (12, iV=119) = 35.31,£> <.0001). There were no 
interactive effects for age and education. Another chi-square analysis demonstrated no 
relationship between dependent variable, decisional style, and the independent variables, 
gender x2 (3, N= 120) = 2.18,/? <,54). Table 4-4 demonstrates the number of participants 
in each decisional stvle based on their education level. 



7 


8 


13 


32.8% 


15 





1 


22.7% 


17 


2 


6 


41.2% 


1 








3.4% 



140 

Table 4-4 

Decisional style by education level (Chi-square 35.312, significant at p > .0001) 

Elementary Completed HS Some college College degree Grad degree Total 

Active 
Deciding 2 9 

Passive 

Deciding 5 6 

Mindless 
Deciding 8 16 

Ruminating 3 

The relationship between age and decisional style was analyzed using an analysis of 
variance resulting in a significant difference. The mean age of active decisional style was 
51.8, passive decisional style was 56.2, mindless decisional style was 59.7, and ruminating 
style was 56 F (3, 116) = 3.08, p < .03). This finding would lead one to believe that the 
younger a person is, the more likely he/she is to be an active decider. 

Another two-way analysis of variance was conducted using age x gender as the 
independent variable and decisional style as the dependent variable. This anova resulted in 
a significant F (7, 1 12) = 2.35, p < .03). Results are demonstrated in the following table. 
Far less variation is reflected with women's ages between decisional styles than with men's 
ages between decisional style. To test whether there was a correlation between age and 
education level a Pearson Correlation Coefficient was conducted resulting in an 
insignificant r = -.05. The results are found in Table 4-5. 



141 



Table 4-5 

Relationship of Age and Gender by Decisional Style F (7,1 12) = 2.35, p < 03) 







Males 






Females 




Category 


Age 


SD 


N 


Age 


SD 


N 


Active deciding 


53 


14.8 


14 


50 


12.4 


25 


Passive deciding 


59 


6.4 


7 


55 


11.6 


20 


Mindless deciding 


63 


8.4 


21 


56 


13.1 


29 


Ruminating 


69 




1 


51 


15 


3 



Medical Data Effects 

To determine how the actual medical situation affected participants' decisional style, 
chi square analyses were also conducted on each patient's medical data. Stage of cancer 
and prognosis were determined by the participant's attending oncologist. Time since the 
diagnosis and record of recurrences were gathered from the medical records. No 
significant differences were found between patients' decisional styles and (1) Stage of 
cancer x2 (9, 7V=89) = 15.26,/? <.08), (2) prognosis assessed on a 1 to 6 scale with one 
being poor and 6 being excellent x2 (12, A=85 = 1 1.55, p < 48), ( 3) time since initial 
diagnosis x2 (12, N=\ 18) = 8.16,/? < 77), (4) or whether the patient's current diagnosis is a 
recurrence or not.r2 (3, N=\ 18) = .56,/? < 91). This sample contained seriously ill people 
with a mean stage of 3.04 and a mean prognosis of 2.91(2 = fair meaning unlikely to live 
three to six months to 3 = guarded, meaning the person is unlikely to live much longer than 



142 
six months). Diagnosis dates varied considerably with a mean of 1.7 years and a median of 

4.4 months. There were two people who previously had cancer over fifteen years prior to 

this study. Their dates of diagnoses were dropped as outliers. The means and standard 

deviations are reported in Table 4-6. 

Table 4-6 

Means and Standard Deviations for Medical Data 

Mean Standard Deviation 

Stage of Cancer 3.04* 1.20 

Prognosis 2.91** 1.51 

Date of Initial Diagnosis 1.7 yrs. (Median 4.4 mo.) 2 

* Stages ranged from 1 meaning non-metastatic and highly probable of a cure to 6 meaning 
highly invasive cancer found in multiple sites of the body. 

**Prognoses ranged from poor meaning less than three to live to excellent meaning full 
remission is anticipated. 

Hypothesis Two: Predicting the Decisional Processing Model 

Hypothesis 2 stated that the Need for Cognition Scale, Need for Closure Scale, 
Padua Inventory - Rumination Scale, and Ability to Process Questionnaire will predict 
decisional style category. Once it was established that people do have different decisional 



143 
styles, there remained two other important purposes for this study. The first was to test 

whether decisional styles are predicted by the elaboration likelihood model variables. 

Hypothesis 2 was tested using a discriminant function analysis to determine the ability of 

the predictor variables to determine decisional category. This hypothesis was supported. 

Each of the ELM constructs, ability, cognitive responding, and motivation and 
rumination were operationalized using four instruments, Need for Cognition Scale, Padua 
Inventory - Rumination Subscale, Need for Closure Scale, and Ability to Process 
Questionnaire as the predictor variables. A Chi-square test was performed to determine 
homogeneity of within covariance matrices. This test resulted in a x2 (30, JV=120) = 
77.41, /x.0001. 

A discriminant function analysis statistically discriminates on the matrix of scales 
between observations (protocols from participants) which determine decisional category. 
The analysis then compares this number with the actual categories the participants fit. One 
would expect chance alone to accurately categorize people 25% of the time. The 
discriminant function resulted in a successful prediction rate of 60%. 

Further examination of the success rates reveal differences in prediction rates for 
each category of decisional style. The active deciders were predicted with a 72% success 
rate, passive deciders were predicted with a 29% success rate; mindless deciders were 
predicted with a 61% success rate, and ruminators were predicted with a 100% success 
rate. 

In three observations, the discriminant function analysis determined inaccurately 
placed participants from the mindless decisional styles and placed them in the passive 



144 
decisional styles. Fourteen participants were removed from the passive decisional style by 
the discriminant function. Of these 14 people, 5 went from the passive decisional style into 
the active decisional style and 9 went from the passive decisional style into the mindless 
decisional style. Theoretically, the only difference between the passive and mindless 
decisional styles is the amount of thought engaged in when concerning treatment decisions. 
Both mindless and passive decisional styles resulted in choosing the recommendation 
provided by the medical system. In the actual data collection, the passive decisional 
category was the most difficult to determine. 

Eight of the miscategorizations made by the discriminant function analysis were 
also the 13 discrepancies which required review by two judges. In these protocols, the self- 
assessment by the patient differed from the investigator's assessment of category. In five of 
these eight protocols, the judges did not agree on the category. For this group of 
participants, categorization proved difficult with every method used. 
Hypothesis Three: Relationship Between Decisional Styles and Coping 

Effects of decisional style on coping. Hypothesis 3 stated that participants in the 
active decisional category use more effective coping strategies than those in the passive 
decisional category and these patients, in turn, use more effective coping strategies than 
those with mindless decisional styles. Past research findings support that people who use 
more coping strategies (Lazarus & Folkman, 1984), more types of coping strategies 
(Dunkel-Schetter, Lazarus, & Folkman, 1992), and certain types of coping strategies 
(Epping-Jordan et al, 1994; Eysenck, 1993; 1994; Ward, Leventhal & Love, 1988) are 
more effective than others in coping with serious illness. 



145 
The patients using ruminating styles were again left out of this analysis due to too 
few ruminating participants. A one-way analysis of variance using the three remaining 
decisional styles as the independent variable and the total Ways of Coping Scale as the 
dependent variable resulted in a significant F(2, 113) = 7.54, p < .0008). Mean scores on 
coping were (a) active decisional style = 10.79 (SD = 2.03), (b) passive decisional style = 
1 1.24 (SD = 1.90), and (c) mindless decisional style = 9.52 (SD = 2.13). See Table 4-8 
for results. This result indicates the patients in the two categories using central route 
processing, active and passive, utilized more coping strategies than those in the mindless 
category. 

The Ways of Coping Scale consists of five subscales: (a) Seek and Use Social 
Support, (b) Focus on the Positive, (c) Distancing, (d) Cognitive Escape-Avoidance, and 
(e) Behavioral Escape-Avoidance. Both raw and relative scores were computed. Raw 
scores allowed for interpretations of both the number of strategies used as well as the 
intensities. Relative scores enabled the computation of proportional scores for descriptive 
purposes indicating the proportion of each participant's use of a particular strategy relative 
to the total strategies used.Means on each subscale of the Ways of Coping Scale are 
reported in Table 4-7 for each decisional style. 

Differences on the total scale indicate the number of coping strategies employed. 
Significant differences occurred between the decisional categories. Examination of the 
means reveals that the direction of this difference was partially predicted by hypothesis 3. 
Participants using active (mean - 10.79) and passive (mean = 1 1.24) decisional styles used 
more coping strategies than those using using mindless (mean = 9.52) decisional style. 



146 



Table 4 - 7 



Means for Five Coping Subscales for each Decisional Style* 



Category Support Positive Focus 



Distance Cognitive Behavioral Total 
Esc-avoid Esc-avoid 



Active 

Passive 

Mindless 



2.54 



2.41 



2.05 



2.36 



2.46 



1.81 



2.34 


2.24 


1.30 


10.79 


2.64 


2.46 


1.25 


11.24 


2.41 


2.12 


1.11 


9.52 



(raw scores: five point scale with = never use to 4 = use very often) 



Table 4-8 



Analysis of Variance for Coping Scales 



Scale 


df 


F value 


P 


Total scale 


2,113 


7.54* 


.0008 


Seek and use support 


2, 113 


8.39* 


.0004 


Focus on the positive 


2,113 


8.88* 


.0003 


Distancing 


2, 113 


2.51 


.08 


Cognitive escape-avoidance 


2,113 


2.43 


.09 


Behavioral escape-avoidance 


2, 113 


1.41 


.24 



147 



To test which differences want statistically significant, /-tests were conducted using 
Bonferrroni correction for the number of tests computed. On overall coping strategies 
used, there was a significant difference between all three categories. People using passive 
decisional styles used significantly more coping strategies than those using active decisional 
styles; people using both active and passive decisional styles used more coping strategies 
than those using mindless decisional style. 

Seeking support and using a positive focus are the specific types of strategies 
comprising this significant difference. Support was used most often in active decisional 
styles, less in passive decisional styles and least in mindless decisional styles. A positive 
focus is used more by participants with passive decisional styles than those with active 
decisional styles and active decisional style participants use positive focus considerably 
more than participants with mindless decisional styles. 

Relative scores were also computed on types of coping strategies and a one-way 
analysis of variance, followed by t-tests with a Bonferroni correction was conducted. The 
relative coping strategies reveal the proportion of the use of one strategy over the others. 
The more types of strategies used, the higher the degree of flexibility in coping (Dunkel- 
Schetter, Lazarus, & Folkman, 1992). Remarkable similarity is shown for the proportions 
of strategies with one exception; participants with mindless decisional styles used a 
significantly larger proportion of distancing than other participants. The difference 
between the mindless and the active decisional styles was significant. 

Two frames of reference were used to categorize people in decisional categories: 
one was Ellen Langer's decisional categones (active, passive, and mindless) and the other, 



1 



148 
was Petty and Cacioppo's information processing model (central vs. peripheral route 
processing). Superimposing Petty and Cacioppo's model upon Langer's model places both 
active and passive decisional styles into the category of central route processing and both 
mindless and ruminating decisional styles into peripheral route processing. 

Additional one way analyses of variance were conducted to determine differences 
between people who make their medical decisions using central route processing and those 
who use peripheral route processing. Central route processors used significantly more 
coping strategies than peripheral route processors F{\, 1 1 8) = 1 1 . 88, p >0008). Central 
route processors were higher on seeking and using support F{\, 118) = 14.62,/? > .0002), 
focusing on the positive F(l, 118)= 17.42,/? > .000] ). When determining the ratio of 
coping strategies used, peripheral route processors used significantly more distancing F(l, 
118) = 8.22, p >.005). Although the means were different it did not reach significance 
when using three categories of decisional styles for the analysis on the ratio of strategies 
used. When using central and peripheral route processing as the categories, the ratio of 
focusing on the positive was significantly higher for central route processors F(l, 11 8) = 
6.95,/? >. 009). 

Hypothesis 3 stated that patients demonstrating active decisional styles would be 
greater than those using passive decisional styles and that patients in both of those 
categories would be significantly more effective in coping than either mindless or 
ruminating decisional style participants. The Ways of Coping Scale was used to measure 
coping in this analysis. The Ways of Coping Scale consists of three parts: First is the issue 
the participant found most troubling and the second is the perceived degree of distress 




i 

■■■*■■ 

I 

I 






.. 149 
caused by that issue. As described previously, these two questions were used as a testing 
strategy so the patient could use a reference point in answering the questions about coping 
strategies used. This study sought information related to how patients coped with the most 
stressful part of their cancer. 
Most Troublesome Part of Cancer 

Five choices of issues that cancer patients find troublesome were provided. They 
were (a) fear of future due to cancer, (b) limitations in physical abilities, lifestyle, or 
appearance due to cancer, (c) pain or discomfort from illness or treatment, (d) problems 
with family or friends due to cancer, and (e) other. The frequency of each problem within 
each decisional category is reported in Table 4-10. 



Table 4-9 

Frequency within Decisional Styles for Most Troublesome Part of Cancer Question 



Category Fear of Future Limitations Pain and Discomfort 



Active deciding 19 11 7 

Passive deciding 15 5 4 

Mindless deciding 17 16 9 

Total 51 32 20 



Although many more people listed fear of the future as the primary stressor, there 
were no significant differences based on decisional style x2 (12,JV= 115) = 12. 573, p 
< -40. However, sixty percent of the cells had expected counts less than 5, which may 



150 
render the Chi-square an invalid test. In the initial analysis, the following cells had small 
numbers: ruminating category of decisional style and the fourth and fifth choices on the 
coping question (problems with family and other). In order to conduct a more valid test, 
these categories were eliminated. A Chi-square was then performed on three decisional 
styles and the first three choices on the coping question, resulting again in insignificant 
findings x2 (4, A*= 1 03) = 3.22, p < .52). According to the results of both tests, there was 
no difference in the most troublesome issue related to cancer, based on decisional style. 
For all categories, fear of the future was designated by 49.5% of the participants, 31% 
identified limitations due to the cancer, and 19.4% identified pain and discomfort as 
causing the most distress. 
Amount of Stress Generated by the Most Troublesome Part of Cancer 

The second aspect of coping was the amount of distress caused by the issue 
identified as most troublesome. A one-way analysis of variance resulted in a nonsignificant 
relationship between decisional style and the amount of distress reported by the participants 
F(2, 117) = 35,p>.70). On a five-point scale with 1 meaning extremely stressful, patients 
using active decisional styles had a mean of 2.25 (SD = 1.04), those using passive 
decisional styles had a mean of 2.48 (SD = 1.15), and those using mindless decisional 
styles had a mean of 2.56 (SD = 1.05). That places the majority of the participants 
between somewhat stressful (3) and stressful (2) regardless of decisional style. 

Further investigation into the amount of distress generated by the most troubling 
issue led to significant results F(4, 1 10) = 2.61,/? >.04). Although fear of the future was 
the issue most frequently cited as most stressful (n = 53), the mean amount of distress 



151 
created by this issue was only 2. 1 8 on a 5 point scale. The item identified second most 
often as the most troubling, limitations due to cancer, (n= 33) had a mean distress level of 
2.72. The highest stress level was reported for "other" which was typically identified as 
financial concerns (mean = 3.4). 

However, on closer observation, only four participants chose family and friends as 
the most troublesome issue and five participants named financial concerns rendering the 
fourth and fifth choices for the question of issues about coping with too few people for 
statistical analysis. Therefore, another anova was conducted after dropping the last two 
categories. This comparison between the interaction of stress level and most troublesome 
issue (fear of future, limitations, and pain) was found insignificant F (2, 103) = 2.78,/? < 
.06). In this study, the issue found most difficult for the participant failed to significantly 
influence the level of perceived stress. Neither the issue identified as difficult nor the level 
of perceived stress were related to the decisional style of the participant. These factors 
remain undetermined for the ruminating category. 
Hypotheses 4 through 7: Relationship of Each Scale to Decisional Category 

In order to determine the predictability of the overall model it was necessary to test 
the predictive ability of each instrument individually. Hypotheses 4 through 7 tested each 
instrument independently using a one-way anovas for unequal cells. The continuous 
variables in the four anovas, respectively, were the Need for Cognition, Need for Closure, 
Ability to Process, and Padua Inventory, Rumination Subscale. The categorical variable in 
the anovas for all four hypotheses was the decisional style categories. Three of the four of 
these hypotheses were unsupported, providing evidence of the need for the overall model 



152 
in order to predict decisional styles. Taken alone, the Need for Cognition Scale, Ability to 
Process Questionnaire, and Padua Inventory did not result in a significant relationship with 
decisional style. Need for Closure was statistically significant. 

These hypotheses tested the relationship between decisional style and each scale 
used to operationalize the four predictor variables. The independent variable was 
decisional style but, rather than using all four categories, the analysis used only three. The 
fourth category, ruminating, was dropped because the cell contained only four participants. 
Categories used were active, passive, and mindless deciding. The dependent variables 
differed for each hypothesis tested. 
Hypothesis 4 - Need for Cognition Scale 

Hypothesis four stated that patients with active decisional styles would score higher 
than those with passive decisional styles, which would score higher than those using 
mindless decisional styles or ruminating on the Need for Cognition Scale. This hypothesis 
was not supported. No significant differences were demonstrated between active, passive 
and mindless deciders F(2, 113) = 1.77,/? < 17). Means and standard deviations for each 
category are reported in Table 4-10. 

Table 4-10 

Means and Standard Deviations on Need for Cognition Scale 



Category 


N 


Mean 


Standard De 


Active deciding 


39 


4.10 


.88 


Passive deciding 


27 


3.94 


.84 


Mindless deciding 


50 


3.74 


.92 



153 
Hypothesis Five - Need for Closure Scale 

Hypothesis 5 stated that patients with mindless decisional styles would score higher 
on need for closure than those who use ruminating styles, that scores of patients using 
ruminating would be equal to those patients with active decisional styles, and that all three 
kinds of patients would score higher than those with passive decisional styles on the Need 
for Closure Scale. Because the analysis conducted could not include ruminating, the 
analysis could actually test only the following hypothesis: those using mindless decisional 
styles would score higher than those using active decisional styles and both would score 
higher than patients with passive decisional styles on the Need for Closure Scale. This 
hypothesis was partially supported. Mean scores of patients with mindless decisional styles 
and passive decisional styles did not significantly differ, but significantly differed from 
active decisional styles F(2, 92) = 4.47,/? < .014). Patients using mindless and passive 
decisional styles had a greater demonstrated need for closure than those using active 
decisional styles. Table 4-1 1 contains the means and standard deviations on the Need for 
Closure Scale. 

Table 4-11 " ~ 

Means and Standard Deviations on Need for Closure Scale 

Category N Means Standard Deviation 

Active deciding 36 3.95 .42 

Passive deciding 21 4.23 .49 

Mindless deciding 38 4.23 .44 



154 
Hypothesis 6 - Padua Inventory - Rumination Subscale 

Hypothesis 6 stated that on the Rumination Subscale, ruminating participants would 
score higher than members of any of the other categories. It further stated that active 
decisional style and passive decisional style would be equal, and both would score higher 
than mindless decisional styles. This hypothesis was not supported by the data F(2, 1 13) = 
.10 p < .91). Instead very few differences existed among patients using the three decisional 
styles on the rumination subscale. The Padua Rumination Subscale is not predictive of the 
three decisional categories analyzed. Means and standard deviations are listed in Table 4- 
12. 



Table 4 -12 

Table of Means and Standard Deviations for Rumination Subscale for decisional styles 



Category N Means Standard 

Deviations 



Active deciding 39 .658 .596 

Passive deciding 27 .656 .453 

Mindless deciding 50 .616 .443 



Hypothesis 7 - Ability to Process Questionnaire 

The Ability to Process Questionnaire was created for this study by Martin 
Heesacker (personal communication, February 5, 1997). Each question was based on 
research drawn from literature on central and peripheral processing of information and on 
investigation of those factors which interfere with the ability to process information. Each 
question tapped a different variable: ability, distraction, time, preoccupation, and emotional 



155 
distress. A factor analysis was conducted on this Ability to Process Questionnaire. A 
principle components analysis suggested one factor. Cronbach's Alpha for the scale was 
.80, which also supports the single-factor conclusion regarding this scale. 

Hypothesis 7 stated that patients with active decisional styles and passive decisional 
styles were equal on the Ability to Process Questionnaire and both groups would have 
higher mean scores than those patients with ruminating and mindless decisional styles. It 
further stated that ruminating style would be greater than mindless decisional style on the 
Ability to Process Questionnaire. The hypothesis was unsupported F (2, 113) = .59, p < 
.55). Again, very few differences were found between decisional styles indicating that the 
Ability to Process Questionnaire is not predictive when used alone. Means and standard 
deviations are reported in Table 4-13. 

Table 4-13 

Means and Standard Deviations for Ability to Process Questionnaire for decisional styles 
Category N Means Standard Deviation 

Active deciding 39 2.04 .64 

Passive deciding 27 1.99 .64 

Mindless deciding 50 2.16 .74 

In summary, consistent with hypothesis 1 , the participants in this study did indeed 
use different decisional styles. The decisional styles were unrelated to the severity or 
prognosis of the illness, amount of time since diagnosis, or whether the cancer was a 
reoccurrence. Decisional styles were, however, related to education. Decisional styles 



156 
were assessed using three different methods which resulted in the identical categorization 
of 103 of the 120 participants. The categorization of the participants into the four 
categories proved to be highly reliable. 

The second hypothesis of this study was assessed via the discriminant function 
analysis to determine if the elaboration likelihood model variables, together with the Padua 
Rumination Scale, would predict decisional styles. This hypothesis was supported. Sixty 
percent of the participants were accurately categorized using these predictor variables. 
This figure is 35% higher than the 25% if predictions were made by chance. 

In support of hypothesis 3, significant differences were found among patients with 
different decisional styles on both the amount and type of coping strategies used. 
Specifically, active and passive deciders used considerably more coping strategies and more 
effective coping strategies than mindless deciders. No analyses were conducted on the 
ruminating category because there were too few participants in this category. This study 
provides some evidence that patients use different decisional styles and the four categories 
in the decisional processing model are valid. Further evidence is provided in this study 
suggesting decisional styles and effective coping are related. 



CHAPTER FIVE 
DISCUSSION OF RESULTS 



Chapter Five provides a summary of the results supporting the three main 
hypotheses and the decisional processing model. The theoretical implications regarding the 
extension of the theory of mindfulness and the elaboration likelihood model into medical 
decision making are addressed. Practice implications are also included. The chapter closes 
with methodological issues and new research questions generated by the results of this 
study. 

Medical delivery system is beginning to recognize a general movement toward a 
more educated, involved consumer approach by patients (Hodne, 1995). Patients are 
assuming a greater role in choosing treatments, including regimens unknown to their 
treating physician (Jacobs, 1993). Even major funding sources, such as the National 
Institute of Health, are placing quality of life issues on their agenda in anticipation of a 
future in which Americans will be facing limitations in their health care (Cynthia Bellar, 
personal communication). These indicators suggest that patients will be considerably more 
involved in making their medical decisions. 

Research in medical decision making literature focuses primarily on the physician's 
decisions whereas only a handful of studies address the patient's role in decision-making. 
A few studies suggest that patients do not wish to be involved in their medical decisions 

157 



158 
(Ende, Kazis, & Moskowitz, 1989; Strull, Lo, & Charles, 1984) but other studies conclude 
that more patients do wish involvement (Blanchard, Labrecque, Ruckdeschel, & 
Blanchard, 1988; Cassileth, Zupkis, Sutton-Smith, & March, 1980; Degner, Kristjanson, 
Bowman, Sloan, Carriere, O'Neill, Bilodeau, 1997). Because patient's decisions are 
directly related to adherence, outcomes, and coping, it is essential to understand their 
decision-making process. 

Relationships between personality variables and coping styles have been shown to 
affect incidence, progression of disease, and survival. Studies have demonstrated 
significant synergistic effects between physical and psychological factors. About half the 
variance in predicting cancer is due to personality and coping factors (Eysenck, 1988). In a 
review of personality, coping, and cancer, Eysenck (1994) concluded a need for an 
integrated model predictive of coping, occurrence, progression, and survival. 

Underlying many of the above factors affecting cancer are decisions about such 
issues as attribution of causality, self-efficacy, the use of coping strategies, and treatment 
regimens. Essential to building a model of personality, coping, and cancer, is a greater 
understanding of how these important predictors of cancer are determined. This study 
proposed to begin a program of research that leads to a model of decision making that 
could be useful in impacting those factors critical to effective coping, limiting disease 
progression, and enhancing survival. 
Summary of Results 

Three main hypotheses were used to test a model of medical decision making and 
it's relationship to coping. The results testing the first hypothesis established the existence 



159 
of four decisional styles. Three of the decisional styles were statistically supported. The 
fourth, ruminating, contained few participants but enjoyed perfect agreement between all 
methods of measuring. This category could not be included in the empirical testing of the 
hypotheses due to the small number of patients. The second hypothesis, testing the ability 
of the elaboration likelihood contracts to accurately predict decisional style, was supported. 
Hypothesis three, stating that patients using certain decisional styles were more effective 
than others in coping was also supported. The Need for Closure variable was the only 
ancillary hypothesis that was supported. No relationship was found between any other 
variable and decisional style, indicating that the scales by themselves were not 
predictive. 

Another major finding was that a majority of people engaged in mindless deciding 
about an event as serious as a life-threatening illness. How patients made decisions about 
their medical treatment was related to decisional style and unrelated to either medical data 
or most descriptive variables. The only variables that correlated significantly with 
decisional style were education and age. 

Theoretical questions were also examined in this study. In building a model of 
decisional styles, the elaboration likelihood model of Petty and Cacioppo (1981) and Ellen 
Langer's theory of mindfulness were integrated. The integration of these two theories was 
supported by the findings of the present study. Evidence was generated that the four 
decisional categories indeed fit into two groups, central and peripheral processing routes. 



160 
Decisional Categories 

The use of four decisional styles in the proposed model was supported. Inclusion 
of the three decisional styles identified by Langer (1994) received strong support. In 
support of Langer"s theory, 41% of the participants used the mindless decisional style. The 
active and passive decisional styles were used by 32.5% and 22%, respectively. The 
ruminating style contained 3.3% of the participants. Although there were very few 
participants in the fourth category, there was total agreement among the participants, the 
investigator, and the judges about their style of deciding. Furthermore, this style was 
perfectly predicted by the discriminant function analysis (100%). 
Mindless Decisional Style 

In mindless decisional styles people rely on peripheral cues to make a choice. 
Many of the participants in this study who used the mindless style made treatment 
decisions as serious as whether or not to get a bone marrow transplant within less than five 
minutes and without leaving the doctor's office. They placed their faith in the authority and 
reputation of their doctor or the facility. Since most of the interviews took place with a 
spouse present, additional conversations occurred revealing that the mindless deciding in 
which the patient engaged was often offset by a different style of deciding conducted by 
the spouse. Some patients in the mindless category followed their spouses' advice as 
unquestioningly as others followed their physicians' advice. They, themselves, still engaged 
in no thoughtful decision-making. 

Langer's theory postulates that mindless deciding is making a premature cognitive 
commitment based on pre-existing schema. It is within the mindless decisional style that 



161 
evidence of this pre-existing schema is discovered. Decisions have been shown to be 

influenced by framing effects (Tversky & Kahneman, 1981) in a study using a hypothetical 

life-death story. When presented in the frame of saving lives, the majority choice (72%) 

was risk aversive; when presented in the frame of losing lives, the majority (78%) took 

risks. Such framing effects were subsequently found to extend to processing operations. 

Tversky and Kahneman (1985,1986, 1992) advanced the idea that people engage in two 

phases when making risky choices: editing and evaluating. The first operation in this 

sequence is coding into a "loss" or a "gain" problem and this coding was affected by 

framing. 

However, these studies were context independent. In a series of experiments 
manipulating context, findings revealed a framing effect when a life and death story was 
associated with unidentified people but, when the story was associated with their own 
family members, no framing effect was demonstrated (Wang & Johnston, 1995). When 
placing their own family in the life and death situation, participants overwhelmingly chose 
the riskier decision. The frame of reference was no longer the frame presented to them but 
was replaced with their own frame and, in the family context, the frame was unanimously a 
"loss". This reference point begins the association with a pre-existing schema and the 
schemata operates in framing the decision. It is this individual coding (meaning) attached 
to an event that determines the associations with pre-existing schemata. 

The current study provides supportive evidence of such schema. Many of the 
patients in the mindless category spoke of their pre-existing schemas, usually the reputation 



162 
of the facility, as the reason for their decision. They acknowledged that they decided to 
take the physician's advice prior to meeting the physician. 

Similar to the Wang and Johnston (1995) study in which framing effects 
diminished when participants thought of their own family members in the situation, the 
decisions in this study were even more highly contextualized and therefore resistant to 
external framing effects. Cancer is a silent illness that begins asymptomatic and often 
advances considerably before diagnosis occurs. If a patient felt he/she were healthy, as 
expressed by those in this study, and was suddenly confronted with cancer, it is very likely 
he/she would frame the experience as a loss. Among the mindless deciders, their decisions 
were made prior to the physician offering any frame of reference, indicating the framing of 
their decisions was their pre-existing schema. 

According to the prior research, framing the illness as a loss should have resulted in 
a riskier decision when it came to treatment. It is unclear from the current research if 
"leaving it to the physician" is considered riskier than more involvement in their treatment 
decision. Given that these participants were also the ones who demonstrated a significant 
need for closure (hypothesized by Kruglanski as a motivator to reduce anxiety), it is more 
likely that they chose the least risky route in order to reduce their distress. There is a 
difference between this study using participants whose lives are actually threatened by the 
illness and those in the decision-making studies using hypothetical examples. The 
difference may lie in the degree of emotional involvement. Although this study suggests 
that a more threatening context may influence framing effects, further research is needed to 



163 
clarify this relationship. If people do use different decisional styles, perhaps the framing 

effects vary based on these decisional styles. 

As theorized, people in the mindless decisional category made a premature 
cognitive commitment to a process. In contrast to decision making literature, these results 
did not support the hypothesized framing effects demonstrated in other studies on 
contextualization of decisions. 

A possible explanation for the large proportion of participants in the mindless 
decisional category can be found in the patient-physician communication literature. 
Participants in this category reported making their decisions in less than five minutes or, in 
the absence of any information, beyond one time-limited conversation with a physician. 
Time spent with a physician (more than 19 minutes) (Beisecker & Beisecker, 1990) and 
longer acquaintance with a physician (Waitskin, 1985) has been associated with more 
information seeking behavior and more active patient participation in decisions. According 
to an informal and limited survey of the staff at the facility in which the current study was 
conducted, the physicians spend thirty to fourty minutes during the patients initial 
appointments. The decisions assessed in the current study were those made at the 
beginning of their treatment at this facility. It is likely that only a few patients in this study 
had a prior relationship with the oncologist. It is unlikely that patients were categorized in 
the mindless decisional style because of either limited time with the treating physician or a 
long-standing relationship with the physician. 

Langer postulated that neither active nor passive deciding takes place when only 
one alternative is provided. In the present study, it was not unusual for the physician to 



164 
recommend one course of treatment. This lack of options did not inhibit the participants 
who chose to go further or to think about whether or not they wanted to be treated. Those 
in the active decisional category initiated further information search anyway. However, 
many of the patients felt as if they had no choice when presented with one option. For 
those participants, follow up questions often surfaced decisions made according to pre- 
existing schema, and they were categorized in the mindless decisional style. 

Previous investigations of mindless decisions were conducted under conditions in 
which decisions based on commitments made to a pre-existing schema were outside of the 
awareness of the participants. The current study, in contrast, demonstrated participants' 
use of mindless decision-making under conditions in which they were confronted with 
taking a course of action based on their decision. This study extended the generalizability 
of research on mindless decisonal styles to include people who were aware of making a 
decision. In this sample, under critical conditions, mindless deciding occurred even when 
the decision was consciously made and the style of deciding acknowledged. 
Active and Passive Decisional Styles 

The active decisional category contained 32% and the passive decisional category 
contained 22%. Interpreting Langer"s writings, this appears to be a higher-than-expected 
number of patients, especially in the active decisional category. Active and passive 
deciders both engaged in effortful thought but only active deciders sought additional 
information. Both groups maintained a sense of control even when they ultimately chose 
the physician's recommendations. Patients in another study were found to report a greater 
sense of control and improved health when they actively participated in the decisions about 



165 
their treatment (Brody, Miller, Lerman, Smith, & Caputo, 1989). In other studies, a sense 

of control has been identified as affecting adherence to medical regimens (Leidy & Haase, 
1996), survival and coping (Epping- Jordan et al, 1994). 

Langer theorized a discrimination between active and passive deciding based on the 
initiative displayed by the patient in gathering information and the consideration given to 
the options generated. This distinction was upheld in the current study. These active 
decisional style patients sought information from the internet, the library, the American 
Cancer Society information line, and medical journals. They entered self-awareness into 
the equation and generated their own opinions. The passive decisional style patients in the 
current study gave a great deal of serious consideration to everything presented to them. 
They often took notes during appointments with the physician. However, they displayed 
no initiative to search beyond what was presented to them. The distinction between active 
and passive decisional styles was upheld in the patterns presented by the participants in this 
study. 

Active decisional styles and mindless decisional styles were readily identified. 
Passive decisional style was the most difficult to identify regardless of method used 
(decision tree, independent judges or the discriminant function analysis). Similar to this 
study, most of the distinctions drawn from research on Langer's theory have been between 
mindlessness and mindfulness (active deciding). In Langer's studies (for example: Langer 
& Williams, 1992) passive deciding, if it occurred at all, was not a naturally occurring 
event. The present study was conducted under naturalistic conditions. The difficulty 
confronted in identifying the passive decisional category as clearly as the others in the 



166 
current study may be explained by semantics. Passive deciding is theoretically similar to 
active deciding (ie. central route processing) but shares the same outcome with mindless 
deciding (Doctor's recommendation). If, when participants are questioned the emphasis is 
placed on the outcomes, i.e. "going along with the physician's recommendations", passive 
deciding can be confused with mindless deciding. Theoretically, active and passive 
decisional styles are more closely related because they both describe a process of effortful 
thought and deep consideration. This research clearly supported the distinction between 
active and passive decisional categories as Langer theorized. 

Although the passive decisional category was statistically significant, it had the most 
discrepancies of all the categories. Perhaps the difficulty in drawing a line indicates that, 
rather than existing in structured categories in the natural world, decisional styles may 
reside on a continuum. Each person may fluctuate in his/her decisional styles within a 
certain range, sensitive to the environmental and internal factors empirically demonstrated 
to influence routes of processing information. It is possible that there are degrees of active, 
passive, and mindless decisional styles. 

It is also possible that decisional styles are situation-specific rather than global. 
There were two indicators in the data-gathering process indicating this possibility. Men 
who had attained positions in life that generally require decisiveness (CEO's of major 
corporations, attorneys, university professors, and researchers) were often surprisingly 
represented in the mindless category concerning their medical decision-making. 

A mediating variable may be operating in determining which style is used for each 
situation. One study found that elderly people were more likely than younger people to 



167 
want decision-making participation (Woodward & Wallston, 1987). The intervening 
variable that explained this finding was the difference in the degree of self-efficacy related 
to health behaviors. Self-efficacy was not included in this study and more research is 
needed to understand the nature of this variable. 
Ruminating Decisional Style 

Ruminating participants felt that their choice was forced, not by medical 
circumstances, but by social circumstances. One woman stated that she was only going 
through treatment because her family was badgering her. Another stated that she went 
along with the physician recommendations, but she doesn't trust it. The four patients in the 
ruminating category were undergoing treatment did not feel committed to the choice. They 
expressed high anxiety, low hopefulness, and often anger. Although the people in the 
ruminating category were few, they were well known to the staff as "being difficult" and 
"making endless demands". Not one patient in any of the other categories was described 
by the staff in this manner. 

Increased anxiety and distress often lead to increased attentiveness to bodily 
sensations and increased misattribution of distress to the illness (Mechanic, 1992). Cancer 
treatment is often described as "worse than the disease" because of the uncomfortable and 
sometimes serious side effects. Increased attention to bodily sensations and the inherent 
discomfort in cancer treatment may lead to labeling the illness as hopeless. Misattribution 
increases body scan behavior. Judgement of progress are determined more by perception 
of these physical sensations than objective information. Individuals with heightened 



168 
anxiety and ambiguous symptoms are more likely to engage in misattribution and seek 
more medical attention (Cameron, Leventhal, & Leventhal, 1995) 

In spite of their small numbers, it may be worthwhile to conduct more research on 
the ruminating group if they are using an inordinate amount of staff time and energy. The 
numbers were too small to statistically test the ruminating category. It is unlikely that the 
people in this category were simply statistical outliers. Participants in the ruminating 
category demonstrated a high degree of internal consistency were decidedly different on 
the predictor variables in the discriminant function analysis. 
Age and decisional style 

The interaction of age and gender was one of the personal variables that 
significantly correlated with decisional styles. Women did not differ in mean age on 
decisional styles. However, significantly more older men were represented in the mindless 
decisional category than women or younger men. 

Several gender differences noted in the interview process may explain this 
difference. More wives than husbands were present for the interviews. Husbands, when 
present, rarely involved themselves. The wives were actively involved, contributing 
explanations to the researcher, reminding their husbands of past behavior, and intently 
listening to the conversation. The traditional of women as care-takers may have precluded 
men in the older age group from actively participating in their medical treatment. 

The differences found in prior research (Degner, Kristjanson, Bowman, Sloan, 
Carriere, CNeil, & Bilodeau, 1997; Woodward & Wallston, 1987) between younger and 
older women in their desire for a more active role in decision making was not supported by 



169 
this study. Both of the prior studies consisted of patients more than two years post- 
diagnosis. Time since diagnosis was found to be predictive of desire for control in the 
Degner study. In contrast, the majority of the participants in the current study had been 
diagnosed less than six months. Time since diagnosis had no effect on their decisional 
style. 
Education and decisional stvle 

Education was also correlated with decisional style. The Need for Cognition Scale 
was not correlated with decisional style, ruling out the likelihood that intrinsic motivation 
led people to put more effort into their decisions as much as education itself. Examination 
of Table 4-2, reveals that people who attended college demonstrate a definite preference 
for active and passive deciding (central route processing) in making medical decisions. 

Active deciding, defined as taking initiative, is the category containing most of the 
college educated participants. Although results do not show reasons for this configuration 
of findings, there are several possible explanations for this differentiation. College 
attendence may teach a person where and how to utilize resources to gain information. 
Another reason may be that the college experience, in teaching students to critically 
evaluate material presented, may reduce blind acceptance of "experts". Yet another reason 
may be that college attendence improves confidence in one's own abilities, enhancing self- 
efficacy. 

In the current study, "some college" could mean someone who took academic 
courses in a four year institution without completion or attended a vocational technical 
school. Vocational colleges seldom teach critical evaluation of academic material, yet 



170 
frequently, those students gain confidence and pride in their accomplishment. The fact 

that this category of education level contains a large number of both passive decisional 

styles and mindless decisional styles is consistent with the notion that knowledge about 

utilization of academic resources and the ability to critically evaluate important material 

may be the reasons driving this decision-making behavior. Resource utilization and 

evaluation skills are teachable and could be incorporated into a psychoeducation program 

for cancer patients. 

In the Degner (1997) study on women with breast cancer, education level was the 
best predictor of preferences for involvement in decision making. The Degner sample 
included a large number of low education, elderly people, whereas the current study 
extended these findings by including an unusually large number of highly educated, 
middle-aged people. The Waitzkin study (1985) also reported patients with a higher 
education level, a higher socio-economic level, and women demonstrated increased desire 
for information and participation. 
Race and decisional style 

Non-significant results related to race must be viewed with caution. Racial 
composition of the study included a small number of African- Americans, Hispanics, and 
Asians and therefore they were grouped together as non-whites and then compared with 
whites. It is not possible to know if the sample was representative of the population 
because statistics are not kept by Shands Cancer Center on the racial make-up of the 
population served. In addition, there is growing evidence in the literature that including 
people who are culturally different in a statistical analysis in which they are grouped with a 



171 
another minority, reveals very little about that population. Although efforts were made to 
incorporate different races in this study in large enough numbers to be able to conduct 
adequate analyses, there simply were not enough non-whites seeking services at the 
treatment center during the four weeks in which this study was conducted to do so. To 
state, even equivocally, that race is unrelated to decisional styles would be overstating the 
results of this study. 

A debriefing of the researchers by the principle investigator following the data 
collection reached a general consensus that African-Americans who demonstrated a 
mindless decisional style put their trust in their religious beliefs, not the physician or the 
facility, as was common among the whites. Follow-up studies are needed to determine 
decisional styles for people of different cultural experiences. 
Medical data and decisional style 

The majority of people in the current study were recently diagnosed with pervasive 
cancer and given limited life expectancies, yet their decisional styles were unrelated to any 
of these factors. Time since diagnosis (mean =3.71 months) in this sample was 
considerably less than the time since diagnosis in other studies on decision-making. Degner 
et al (1997) with a mean = 4.7 years since diagnosis, reported that women who were closer 
to diagnosis were less likely to prefer active roles in decision-making. 

Another difference between the current study and previous reseach is the level of 
disease in the patients. The mean level of disease was stage 3.04. Women with less 
advanced cancers wanted more participation than those with more advanced cancers 
(Degner et al, 1997). Less than 10% of the Degner sample was above a stage II meaning 



172 
that most of their participants were considerably less ill than those in the current study. 
The Degner study was conducted on breast cancer patients only, typically more vocal than 
any other group of cancer patients. Differences found in the Degner results and these 
results may reflect differences in the sample. However, these differences again raise the 
question whether decisional styles are situation-specific or global. 
Limitations 

The sample contained an inordinate number of people with advanced degrees. 
Education was a factor in discriminating between decisional styles. It is possible that if this 
study were conducted in a geographic location less dominated by a major university, more 
people would be categorized in the mindless decisional category. 

Elaboration Likelihood Model As Predictive of Decisional Style 
Two Routes of Processing 

One of the purposes of the current study was to find evidence supporting the 
integration of Langer"s theory of decision-making (1989) and the social influence theory of 
Petty and Cacioppo (1986). Social influence theorists have identified two routes of 
processing. Petty and Cacioppo (1986) called these routes, central and peripheral. 

According to Petty and Cacioppo (1986), central route processing requires effortful 
thought, discrimination between options, an investment of time, and a response. Further 
investigation demonstrated that these variables were affected by distraction, amount of 
involvement, motivation to process, and emotional state, as well as how the message was 
presented. The same description also defines the parameters of Langer's theory. Central 



173 
route processing is analogous to Langer's active and passive deciding; peripheral route 
processing is analogous to mindless deciding. 

The results of the current study supported the proposed integration of theories. In 
every method of measuring, participants were found to fall into active, passive, and 
mindless decisional categories. Those factors common to both theories were used to 
describe decisional styles. It is legitimate to consider both active and passive decisional 
styles as central route processing. There were more similarities than differences in the two 
styles. Both styles involved effortful thought, considerable time, a continuing search for 
more information, an openness to new information, reasonable certainty of the decision, 
and devoid of excessive worry. Both active and passive deciding can be considered 
central route processing. 

On the other hand the participants in this study using mindless deciding, 
demonstrated a clear response to cues that triggered a pre-existing schema. This pattern of 
deciding describes peripheral route processing. 

One discrepancy remains unsettled. Langer's theory suggests that when a cognitive 
commitment is made to a pre-existing schema, a person is more certain he/she made the 
right decision. Petty and Cacioppo's theory suggests that when a choice is made through 
peripheral route processing, it is subject to change when a different cue presents itself. 
This discrepancy may be clarified through the work on availability of cues conducted by 
Fazio (1993). Fazio suggests that the strength of the association will determine the 
availability of a cue and that a person processing in a peripheral manner will respond to the 



174 
most available cue. It is possible that the certainty expressed by these patients results from 
the strength of the cue that triggered the response. 

For example, Joe was told by his family doctor that Shands Cancer Center had the 
best medical care. Based on that cue, Joe made a quick decision that, when he went to 
Shands, he would accept whatever the (unknown at that point) oncologist recommended. 
In an effort to reduce his anxiety about his future (reflecting Kruglanski's theory), Joe 
remained closed to any competing information, thereby increasing the availability and 
strength of the association and decreasing the likelihood that any other information could 
be associated with recovery in his mind. The strength of association and the availability of 
the schema may account for the certainty of these decisions in spite of the fact that these 
patients exhibited peripheral route processing. 
Predictive Ability of ELM 

Use of the constructs of the elaboration likelihood model (ELM) to predict 
decisional style was supported by this study. With the exception of the need for closure, 
none of the variables could independently predict into which category a person would be 
placed. The elaboration likelihood model postulates that three factors are necessary and 
sufficient to make deep level change by influencing the route of processing. 

Ability to process was measured in a straightforward scale assessing those factors 
which have been demonstrated in research to interfere with central route processing. 
Participants in this study clearly felt they had the ability to make a decision. Even those 
participants who reported making their decision in less than five minutes stated that they 
had sufficient time. 



175 
Motivation is requisite in determining whether a patient will engage in central or 
peripheral route processing. The nonsignificant results on the Need for Cognition Scale 
suggest that motivation to centrally process treatment information is not based on any 
intrinsic need to think more effortfully. It is altogether plausible that whether a person 
enjoys thinking or not would have very little to do with determining whether they put effort 
into such a life and death decision as cancer treatment. 

To understand motivation in this study, the plight of the cancer patients must be 
considered. Need for cognition, while predicting the use of central route processing in 
other situations, does not, by itself, influence the decisional style a patient uses to decide 
medical treatment and coping. But, situational variables may override global need for 
cognition. Some of these situational variables serve to increase the likelihood of central 
route processing and others serve to decrease it. Personal relevance increases the 
likelihood to use central route processing (Petty & Cacioppo, 1979; Petty, Cacioppo, & 
Heesacker, 1981). Unquestionably, motivation to get the best possible treatment for cancer 
would certainly be present and so would personal relevance. However, other situational 
factors may intervene, reversing the tendency to process centrally. 

Increased intensity, as researched by Petty & Cacioppo (1986), was related to 
values. Under conditions which threaten one's deep values, people are likely to invoke self 
protective schemas, thereby processing peripherally. If self-protection is more important 
than thinking effortfully when values are under attack, it can certainly by used by patients 
whose lives are under attack. With increased intensity comes an increased reliance on 
normative information, decreasing the likelihood of central processing. In the elevated 



176 
threat condition that terminal cancer patients face, efforts to reduce the threat most likely 

took precedence over need for cognition in directing their decisional style. 

Another intervening variable may be efficacy. If a person does not feel efficacious 
in making medical decisions in the interest of self-protection, he/she may be more likely to 
use peripheral route processing. Although the relationship between route of processing 
and efficacy has not been researched, efficacy was found to be a factor in determining 
whether a person may wish to be active or passive in making medical decisions (Woodward 
& Wallson, 1987). So, while motivation to process centrally may be present, intrinsically 
and situationally, the relationship is complicated by factors that motivate peripheral route 
processing as well. Another factor affecting how information is processed and decisions 
are made is need for closure. 

Kruglanski and Webster ( 1 996) have concluded that need for closure is also a 
motivator pertinent to decision-making. Therefore another assessment used to 
operationalize motivation was the Need for Closure. 

Need for closure was signicantly related to decisional categories. No differences 
were found between passive and mindless decisional styles but patients using active 
decisional styles had lower need for closure. Kruglanski (in press) stated that in addition to 
an individual disposition, situational factors tend to elevate the need for closure. These 
factors are 1) when the subjective importance of predictability and action are great and 2) 
when the perceived effort to remain open to new ideas is great. Factors which are likely to 
decrease the need for closure are fear of invalidity or paying a high price if one's decision is 
wrong. When making decisions about cancer treatment, the subjective importance of 



177 
action is high and predictability is low. If the wrong treatment is chosen, it could have life- 
threatening consequences, yet when asked if they were at any time afraid of making the 
wrong decision, 71% of the participants answered no or very little. In a person with a 
relatively high need for closure, in a situation that is both life-threatening and 
unpredictable, the fear of invalidity, rather than operating to prompt avoidance of closure, 
may increase the tendency to embrace closure (Kruglanski, in press). 

Fear of invalidity in a high cost situation could lead some people to continue an 
information search and remain open to continued effortful thinking. Others may respond 
to this fear by generating fewer options or suppressing attention to information inconsistent 
with their hypotheses. In this manner, the need for closure is manipulated by a situational 
variable, diagnosis of cancer, that heightens the necessity for the person to act in an 
exaggerated manifestation of his/her characteristic functioning. 

The implication of such 'seizing' upon a solution and 'freezing' it in an illusion of 
certainty is that judgements made in this manner are highly susceptible to peripheral cues. 
All the circumstances related to peripheral route processing are evoked. Patients operating 
in this manner rely more on stereotypes, are subject to primacy effects in impression 
formation, and resort to pre-existing knowledge (Kruglanski & Webster, 1996). 

Cognitive responding is discriminating between options so that they are seen as 
different enough to determine that one is better than another. Cognitive responding was 
operationalized by the Padua Inventory - Rumination Scale and by a question on the 
Decision Tree which asks if respondents had made a decision. An overwhelming majority 



178 
had. The ability to see certain options as more viable than others is inherent in decision- 
making. 

The one category in this study that would not fit the requisite cognitive responding 
is ruminating style . Rumination was not addressed in either the research of Ellen Langer 
or Petty and Cacioppo. Ruminators do not seem to have the ability to commit to a 
cognitive response because they never "settle" on a decision even if they have begun to take 
action. Although the sample was too small to analyze, the ruminators demonstrated 
dramatic differences in mean scores on ability to process. Mean score for the total sample 
was 12.76 and mean score for those in ruminating category was 1 8.8. Low scores indicate 
high ability to process. Ruminators retain a high degree of uncertainty, wondering if the 
other choices may have been better even in the absence of evidence. This constitutes a 
lack of cognitive commitment. Cognitive responding was reflective of people in the active, 
passive, and mindless decisional styles. 

The use of two routes of processing information indicates that both routes may be 
used to process salient messages. A message with strong recommendations may also 
include salient cues, thus rendering each message equally accessible within the person's 
schema. Both routes of processing may be evoked simultaneously, interfering with making 
a cognitive commitment to either. The more a person ruminates, the more the rivalry 
between options is reinforced rather than either option. When combined with the other 
two components of the ELM in a medical decision situation, the motivation would be high 
(especially that affected by fear of invalidity) but the ability to use one mode of processing 
over another may be absent. The association between the ELM constructs and a 



179 
rumination scale found in the current study clarify a process alluded to by Petty and 
Cacioppo. They stated, "The ELM, of course, postulates two routes to persuasion and 
indicates that attitudes can change in the absence of extended issue-relevant thinking if 
salient cues are provided in the persuasion context and people lack the requisite motivation 
and/or ability to engage in message scrutiny" (Petty & Cacioppo, 1 986, p. 181). More 
research may be necessary to determine the effects of simultaneously activating both routes 
of processing. 
Limitations 

The style of presentation by the physician may have influenced the decisional styles 
used by the patients. Prior research has demonstrated that manipulation of the ELM 
variables results in different routes of processing. Whereas the predictive ability of the 
ELM constructs provide some evidence that decisional styles may be influenced by how 
the message is delivered. The predictive ability of the Need for Closure Scale provides 
some evidence that decisional styles are also influenced by individual differences as well. 
This question can only be settled with additional research. 

The associations between theories, constructs, and specific variables in the current 
research are new. The hypotheses tested used these theories in a conceptualization 
radically different than their use in past research Using them in this manner was 
theoretically valid and supported by the results but the methods for operationalizing their 
constructs were created for this study. The study is only as strong as that 
conceptualization. Until more research can be conducted on the model, the results, 
although significant, must be embraced tentatively. 



180 
Decisional Styles and Coping 

Decisional styles were correlated with coping. Patients with active decisional styles 
used more coping strategies than did patients in other categories. Patients using both active 
and passive decisional styles (central route processors) used more strategies to cope than 
patients with mindless decisional styles (peripheral route processors). In addition, those 
with mindless decisional styles used significantly more of the least effective coping 
strategies. 

The first two questions about coping asked the participants about the most 
distressing part of their cancer. Fear of the future was clearly the most distressing aspect 
for all decisional styles. However, those answering fear of the future did not report as 
significant a stress level as those reporting the limitations due to cancer. The most 
prevalent issue was apparently not the most stressful or the one that evokes the most denial. 
Another issue reported as extremely stressful by a low number of participants was the 
category "other" which, for these people, meant financial concern. Although financial 
concern was not listed as an item on the scale used, for those participants not insured, it 
represented a great deal of stress. Had it been asked as part of the scale, it is likely this 
concern would have been reported more frequently. 

In addition, patients appeared to be coping more effectively with the fear of the 
future than with the other issues. The other issues listed, limitations, pain, and financial 
problems tend to confront a person daily, while fear of the future may not. All of these 
daily issues may limit a person's ability to utilize the strategies proven most effective. 
Support is limited if, for financial or medical reasons, a patient is less able to be with 



181 
people. Limitations and pain interfere with maintaining normal routines and hope, making 
it more difficult to focus on the positive. However, neither the issues identified as stressful 
nor the level of perceived stress was related to decisional style. 

Significant differences were found in the total strategies used in the different 
decisional styles. The hypotheses predicted that more strategies would be used in active 
decisional styles than in passive decisional styles. The stress level was also reported higher 
(although not significantly) among those using passive decisional styles. In spite of the 
stress level differences not reaching significance (passive x = 2.52 as opposed to active x = 
2.38), those patients in the passive decisional category may experience more stress and 
therefore be more aware of the need to use coping strategies. They also used more 
distancing, a less functional strategy of coping than support and positive focus, than any 
other category of decisional styles. Patients using passive deciding also had slightly 
elevated scores on cognitive escape-avoidance strategies. Having a positive focus and 
distancing have both received mixed findings in the coping literature (Felton et al, 1984; 
Weisman & Worden, 1976-1977) while cognitive escape-avoidance was found to be 
negatively correlated with effective coping (Felton et al, 1984). 

Perhaps patients in the active decisional styles who use more effective strategies and 
report slightly less perceived stress are simply coping more effectively, in spite of not using 
a larger number of strategies. Supporting this possibility are the significantly more support 
activities engaged in by those in the active decisional category. Positive focus was used by 
participants with passive decisional styles more often than by those with active decisional 
styles but neither of these categories of deciders used positive focus as their primary 



182 
strategy. Active deciders' primary strategy was seeking support whereas passive and 

mindless deciders' primary strategy was distancing. Attempts to distance, labeled threat 

minimization, was associated with increased distress (Weisman & Worden, 1976-1977). 

However, the difference between the passive and mindless categories on coping is that 

patients in the passive category use considerably more strategies along with their distancing. 

Therefore the ratio of distancing to total strategies employed is smaller for those people in 

the passive decisional category. 

The patients using mindless decisional styles reported the most (although 
insignificant) perceived stress. The most frequently used strategy was distancing and 
cognitive escape-avoidance was second in frequency of use. Positive focus was used 
signicantly less frequently than either of the other decisional styles. 

In an exploration of patterns of coping with cancer, Christine Dunkel-Schetter, 
(1992) posed questions about the antecedents that predispose some cancer patients to use 
one coping strategy over other, less effective ones. The current study suggests that 
decisional style may be one of those antecedents. In a comparison between her study of 
668 cancer patients, the sample in the current study was similar with two exceptions: the 
cancer patients in the current study had poorer prognoses and their diagnoses were much 
more recent. Interestingly, in spite of these patients being sicker, the mean perceived stress 
level was considerably lower than the Dunkei-Schetter group. This finding is even more 
surprising when one considers she drew her sample from people much further removed 
from treatment than the present sample. 



183 
The participants in the Dunkel-Schetter study demonstrated little evidence of 

coping styles based on demographics and medical variables. Emotional state was 

significantly associated with all five patterns of coping. Less emotional distress was 

significantly associated with the use of support, focusing on the positive, and distancing. 

More distress was associated with using escape-avoidance behavior. Other studies 

discriminating between affective and cognitive coping styles have found that cognitive 

coping is more effective (Leventhal, 1993). 

By assessing patients within different decisional styles and discovering significant 
differences in the patterns of coping, the current study extends the findings of prior 
research. Consonant with the Dunkel-Schetter study, patients in the current study used 
more distancing and support than any other pattern. However, the variation among the 
three decisional styles did reflect different patterns. 

Coping with distress has also been linked to suppression of emotion and 
inappropriate coping mechanisms. The body of research on suppression of emotion as a 
component of the cancer-prone individual has been generally accepted as a supported 
correlation. The evidence for inappropriate coping mechanisms has shown that there is a 
synergistic effect between coping and physical factors. In one classic study, Kissen (1964) 
determined that "the poorer the outlet for emotional discharge the less exposure to cigarette 
smoke was required to induce lung cancer" (in Eysenck, 1994, p. 172). 

One theory of coping, inoculation theory, was tested in a prospective study of 
women and breast cancer (Cooper & Faragher, 1993). Women who had an acute, severe 
introduction of "problems" in their lives had a significantly higher risk of a malignant 



184 
diagnosis than women who reported a chronic high number of "problems". The Cooper 

and Faragher study provides evidence of a mediating and adaptive coping factor which has 
been associated with self-regulation. Self-regulation refers to the ability to remain flexible, 
alter behavior according to circumstances, and maintain a sense of control and efficacy 
over one's life. In this description it is easy to see the parallels between self-regulation and 
active decisional style. Active decisional style necessitates generating options according to 
"one's own data base rather than normatively derived options" (Shrank & Langer, 1995) 
and leads to enhanced sense of control. Self-regulating types of people were found to be 
task-oriented in their coping styles whereas those found to be cancer prone in prospective 
studies were more emotion-oriented, avoidance-oriented, and distraction-oriented in coping 
styles (Eysenck, 1993). 

Life stressors are mediated by coping strategies and certain strategies have been 
shown to be more effective than others. The effective strategies are consonant with active 
decisional styles and ineffective strategies are consonant with mindless decisional styles. 
The current study supports these conclusions. 
Limitations 

With the exception of the investigation of social support as it affects coping, other 
coping patterns have not been well researched. The body of research suggesting that 
cognitive strategies and active coping styles are more effective is building but still new 
(Cameron, Levenfhal, & Leventhal, 1993; Dunkel-Schetter et al, 1992) The current study 
did not adequately assess the degree of stress or emotional distress experienced by the 
participants. In the one question asked as part of the Ways of Coping Scale, respondents 



185 
reported less stress than in the Dunkel-Schetter et al study (1992) and far less stress than 
one would assume in people with a high probability of a foreshortened future. Denial has 
been identified as characteristic of cancer patients (Eysenck, 1994) and utilized as an 
effective defense (Cameron et al, 1993). Denial was not measured in this research but 
could have been operating in the participants. 

Many of the studies documented in coping literature are either conducted on breast 
cancer patients or include a disproportionate number of breast cancer patients in their 
samples. In spite of breast cancer being one of the most diagnosed forms of cancer, 
reported results may not reflect the experience of other people, especially when one 
considers how rarely men develop breast cancer. Coping has been shown to be situational 
(Lazarus & Folkman, 1984) and various cancers present different problems with which to 
cope. The absence of studies with more diverse diagnoses limit the comparative evidence 
on coping patterns. The question remains unsettled about the advisability of changing 
coping styles to fit particular patterns. 

Decisional Processing Model 

The reason for building a model using an attitude change theory, along with 
Langer's decision-making theory, was to gain an understanding of how to impact decisional 
styles if they proved to relate to coping. It is doubtful there would be a reason to actually 
use the ELM constructs to predict decisional style but it was assumed that //*' the ELM 
constructs could predict different styles, they could be used to implement a change in 
patients. This is entirely consistent with both the theoretical and empirical literature on the 
elaboration likelihood model. The predictive capabilities of these variables were supported. 



186 
Active decisional style was predicted at a success rate of 72%, passive desicional style at 
29%, mindless decisional style at 61%, and ruminating style at 100% success rate. Passive 
decisional style was the only one predicted at a success rate only slightly more than chance. 
These patients were, by far, the most difficult to categorize (see results in Chapter IV). 

Neither the interviewing process nor the instrument assessments found the 
distinctions between passive and mindless decisional styles and between active and passive 
decisional styles as clear cut as distinctions between the other decisional styles. 
Theoretically, patients using both active and passive decisional styles put effortful thought 
into their decisions whereas those using mindless decisional styles put forth no discernable 
effort. In the current study, effortful thought was operational i zed by three questions on the 
decision tree. At times participants responded with a mix of answers on these three 
questions. If one answer showed definite evidence of effortful thought the patients were 
placed in the passive decisional category rather than the mindless category. Passive and 
mindless decisional styles could have been confused because both resulted in taking the 
choices presented by the medical system. It is possible that the low prediction rates for 
passive decisional styles resulted from an initial mis-classification of these participants. 

The judges also struggled with placement on some of these participants who, in 
fact, may use a mix of styles. In spite of the difficulty in categorizing those with passive 
decisional styles, there were definitive differences among these patients on coping. These 
differences lead one to believe that we are indeed tapping into a category of people but that 
category is broader in terms of actual behaviors than previously considered. People within 



187 
the passive decisional style may use behaviors from both active and mindless decisional 
styles. 

What has been learned from the patients in the passive decisional category is that 
decisional styles are either (a) On a continuum with people operating at many different 
points, or (b) More fluid with people moving within a range along the continuum. These 
are questions requiring more research. 

The addition of a category for people who do not "settle" on a decision was 
supported in the current study. Ruminating decisional style was identified by the 
participants, the investigator, and the judges. The ruminating category was predicted by 
the discriminant function analysis 100% of the time as qualitatively different on ELM 
constructs and need for closure. Only five of the 120 participants were categorized as 
ruminating. However, because of the strength of the identification methods, it is 
reasonable to include in the decisional processing model a category of people who do not 
make a commitment to a decision and, therefore, do not make a discriminating cognitive 
response. Certainly more empirical evidence must be gathered in order to understand this 
category and definitively determine it's inclusion. 

Implications of the Study 

The current research was approached with a theoretical and a practical purpose in 
mind. Theoretically, it was designed to build a model of medical decision making that 
would integrate and extend Ellen Langer's theory of mindfulness and Petty and Cacioppo's 
elaboration likelihood model. The practical component involved determining the 
relationship between the theoretical decisional model and coping with life-threatening 



188 
illness. Both the integration of theory and the relationship between decisional styles and 

coping were supported. Implications for this study will be addressed as the findings relate 

to theory, practice, and research. 

Four Decisional Styles: Extension of Langer's Theory 

Ellen Langer identified three decisional categories: active, passive, and mindless. 
She also postulated that when people cannot psychologically discriminate between options, 
they cannot arrive at a commitment. This description sounds like rumination. Using the 
construct of rumination, a fourth category, consonant with Langer's theory, was added to 
the model. It was found that clearly a minority of people use a ruminating style for 
deciding medical treatment. Anecdotal reports from the medical staff indicated that 
ruminators were well-known to the staff for the considerable staff time and attention they 
demanded. The inclusion of this fourth category may provide information for analyzing 
costs and benefits. Perhaps in addition to the patient's decisional style affecting how that 
person copes, makes decisions, or is personally affected, the medical delivery system itself 
is affected by the impact of individuals in this fourth category. 

Attempts at applying the popular cognitively-weighted cost-benefit theories to 
making medical decisions beyond the realm of prevention for which these theories were 
developed have not proven successful. From the number of people in this study who have 
made mindless decisions, an implication might be drawn suggesting that under life- 
threatening situations, these theories are not applicable. The present study clearly supports 
Ellen Langer's conclusions that mindless decisional styles are frequently used in situations 
strongly influencing health issues. 



189 
Using the Elaboration Likelihood Model in Decision-Making - Extension of 
Theory 

The elaboration likelihood model was developed through the investigation of 
attitude change and persuasion. Two routes of processing information were discovered. A 
considerable body of laboratory research has been conducted establishing relative certainty 
that there is a distinct difference in behavior depending on which route is used. That 
research focused predominantly on people's responses to particular messages under 
contrived situations. The current study brought the ELM into the field in which the 
messages received were not controlled. This study provided greater understanding of how 
the ELM operates in a naturally-occurring event. 

The study demonstrated that a relationship exists between decision making and 
routes of processing. The implication of this relationship is that if ELM factors could be 
used to enhance central-route processing and change core attitudes of people in situations 
with less immediacy than cancer treatment, could they also be used to change decisional 
styles by increasing central-route processing of medical decisions. In other words, it 
appears to be possible to use ELM constructs to change decisional styles when it is 
important to do so. If central route processing improves such things as medical decision 
making and coping, what might it do for quality of life issues, sense of control, efficacy, 
and attributions 9 
Implications for Practice 

The literature reporting on the investigation of medical decision making has focused 
on the physician's decision making rather than that of the patients. Very little is actually 



190 
known about how patients process information. Psychological and social factors have been 
identified as influencing adherence to medical regimens, level of disability, and coping. 
Certain factors have been implicated in progression of disease and survival time. These 
psychological factors are decidedly cognitive in nature: attribution of causality, self- 
efficacy, appraisal of both illness and coping, and patterns of coping. These are decisions 
made by the patients not the physicians. In addition, physicians may offer different 
treatment regimens, each carrying differing risks. The regimen to be used becomes the 
patient's decision. Information related to any particular illness abounds through many 
sources and the patients also decide how many other sources are pursued in addition to the 

treatment the physician recommends. Every patient must give informed consent for 
treatment which shifts some responsibility for decision-making to the patient. 

One positive application for both research and practice would be assistance for 
people in understanding how their decisional styles are affecting these important issues. 
Another is the possibility of changing medical decision making by increasing central route 
processing. Another is to look at the interaction between patient and physician, using the 
research on the ELM in order to train physicians to deliver medical information in ways 
that enhance central route processing. 

Until more definitive studies are conducted on decisional style and its' relationship 
with coping, progression, and survival, adventuring into applications would be premature. 
Before implications for practice can be fully understood and ethically applied evidence 
must be accrued indicating that decisional styles are capable of change and that changes 
actually enhance the patient's treatment or subjective experience of the illness. 



191 
Methodological Issues 

The ideas in the current study were built upon the elaboration likelihood model. 
Although the constructs postulated in that model are of interestl91 , they have not been 
operationalized in past research in a manner that allows for generalization to the population 
and the situations studied in the current research. Therefore, the predictor variables in this 
study were based on understanding the theoretical foundation of the ELM constructs and 
seeking instruments and methods which maintained both the spirit and the integrity of the 
ELM. 

The use of the personal interview increased the strength of this study. Information 
was gathered by experienced counselors who consistently make assessments in their 
professions. The interview process ferreted out information about which the patients were 
unaware. For instance, many patients did not realize that they had made a decision but as 
the interview proceded, they began to identify decisions they had made as they revealed 
their narratives. If patients had only been asked a simple question about what decisions 
they made, many would not have explained the process they described to the interviewer 
and, quite possibly, responded negatively. 

Even in the structured part of the interviews some questions were misunderstood. 
The interview process gave an opportunity for the reseacher to clarify and obtain a truer 
meaning of the patient's experience. Using personal interviews rather than questionnaires 
was found to be significantly more successful in predicting studies of personality type 
(Eysenck, 1990). In a large scale prospective study on personality variables related to 



192 
different diseases, marked differences in predictive accuracy was found to depend on the 
degree of interviewer participation (Grossarth-Maticek, Eysenck, & Barrett, 1993). 

Future Research 
A number of questions emerge from these findings. The following questions cover 
three dimensions: characteristics about decisional styles, effects of changing decisional 
styles, and interactions with medical staff and family members based on decisional styles. 
Characteristics about decisional styles 

1. Are decisional styles global or specific, or global within schema rules? In 
Langer's "process commitment," what are common rules of determining schema 
for deciding? Can these schema be changed using the ELM? 

2. Are decisional styles changable? Under what conditions do they naturally 
change? 

3. How are decisional styles developed? 

4. What is different about the ruminator category? 

5. Are decisional styles more appropriately considered on a continuum? 

6. Are there racial/ethnic differences supported by different cultural experiences? 

7. What is the role of emotion in decisional style? 

8. Is cognitive responding interrupted when both routes of processing are activated 
simultaneously? 

9. Can an instrument be developed that assesses global or dominant decisional 
styles? 



193 
Effects of changing decisional styles: 

1. How do decisional styles affect survival time? 

2. Will using the ELM in educational programs change the medical decision 
making route of processing? Under what conditions? Which decisional styles 
are most amenable? 

3. What is the effect of decisional style on quality of life, sense of control, self- 
efficacy, attribution of causality, determination of level of disability, and 
determination of sick role? 

Interactions with others: 

1 . Do decisional styles "run" in families? How does either a compatible or 
complementary decisional style in a spouse affect coping? 

2. Would a change in a patient's decisional style threaten the role of the spouse, 
especially if the spouse is the medical decision-maker in the family 9 

3. What is the effect of the physician's decisional style on interactions with patients 
having either similar or different decisional styles? 

4. How can physicians present information to increase central-route processing in 

patients? 

5. Is there a difference in expenditure of staff resources on patients based on the 
patient's decisional style? 

6. What is the staff response to patients using different decisional styles? 



194 
Conclusion 

Within the last few years, there has been "increasing emphasis on bridging the 
multiple dimensions of human development and behavior (biological, psychological, and 
cultural) and efforts to combine the strengths" of individual theories (Kelly, 1997). The 
current study tested the integration of Langer's theory of mindfulness with Petty and 
Cacioppo's elaboration likelihood model. The integration resulted in a clearer 
understanding of the cognitive processing employed by patients making serious medical 
decisions. The Decisional Processing Model utilizing the ELM constructs of motivation, 
ability, and cognitive responding was predictive of decisional style. The theory of 
mindfulness was supported and expanded to include a fourth decisional category, the 
ruminating style. 

Coping is significantly affected by the decisional style used. A patient facing a life- 
threatening illness makes many decisions about issues as important as self-efficacy, 
appraisal, coping strategies, and attribution. There is an abundance of research literature 
indicating the importance of these factors (decisions) in influencing health. 

Utilization of the ELM in designing psychoeducational programs that enhance 
central route processing in the making of medical decisions may influence the factors 
shown in research to impact severity, progression, and survival time in people with serious 
illness. Educational programs may inspire questioning of patient's pre-existing schemas for 
their validity. Such programs may increase a patient's skills in finding additional 
informative resources and thereby increase self-efficacy when participating in their medical 



194 
decisions. Unconscious attributions and expectations may surface for reconsideration and 
a more mindful approach to the application of coping strategies might be elicited. 

The major purpose of the current study was to test the viability of the Decisional 
Processing Model. Using three categories of decisional styles from Langer's research on 
mindfulness and adding a fourth decisional style, ruminating, the decisional processing 
model was created. The model was tested to determine if it accurately described the styles 
of medical decision-making used by cancer patients and was supported by the data. The 
decisional processing model appears to be a viable model to use in the investigation of 
medical decision-making. 



APPENDIX 
ASSESSMENT INSTRUMENTS 



PARTICIPANT NUMBER 

DESCRIPTIVE DATA: 

1. Gender: Male Female 

2. Race: 

3. Age: 

4. Marital Status: 

5. Education level: 



195 



PARTICIPANT NUMBER 



TYPE OF CANCER 



STAGE OF CANCER 
PROGNOSIS 



196 
MEDICAL DATA FORM 



DATE OF FIRST CANCER DIAGNOSIS 



RECURRENCES OF CANCER: TYPES AND DATES 
TYPE DATE 



COGNITIVE DEFICITS NOTED: YES NO 



197 



DECISION TREE 

1 . What decisions did you have to make relating to your illness (Check all that apply) 

Choices of treatment 

Choices about living arrangements 
Choices about jobs 



Choices about financial plans 

Choices about how treatment may affect your physically 
Choices about what things you needed to do to cope 



Other physical care choices (such as where to put a port for chemo) 
What other choices can you remember having to decide 



197 



2. Of all of these which decision was the most serious to you? 

NOW KEEPING THAT DECISION IN MIND, I'D LIKE TO ASK YOU A FEW 
QUESTIONS RELATED TO HOW YOU THOUGHT ABOUT THE CHOICE. 



3. What choices for treatment were provided by your doctor? 



4. What other things were told to you by the medical staff? 



5. What were your thoughts when you heard ? (Anything else? Repeat until 

participant 

answers no.) 



6. How much time did you think about these before you decided 
dwelled on it 



considerable time 

some time 

very little 



198 
practically none 

7. How much effort do you feel you put into thinking about what to do? 



8. On a scale of 1 to 10, with 1 being "putting it out of your mind almost all the time" and 
being "thinking about it almost all the time", how would you rate the effort you put in? 



9. Did you make a decision? Yes No 



10. If you made a decision, how certain did you feel that you made the right decision? 

Very certain 

Fairly certain 



Had some doubts 
Still doubting it _ 



1 1 . Did you think of other things to do? 



12. If yes, were these other things you thought about considered in your decision-making 1 ; 



13. Did you actively seek information anywhere else? Yes No 

14. What kinds of information" 7 Where? 



15. How much consideration did you give these other suggestions? 



199 
1 6. How did you decide which options you would try? 



17. After making a decision, how certain did you feel? 



18. After making a decision, did you continue to look for more information? 
19 What did you find? How did you learn about that? 

20. What were your thoughts in response to the new information? 



21. Did you change anything based on the new information? 



22. After thinking about your choices for awhile, did you get to the point when it became 
too tiresome to think about it anymore? 

Yes Yes, but I still persisted ______ No 

23. How soon after you knew you had cancer did you get to that point? 

24. How much do you continue to worry about whether you made the right decision? 



25. Were you afraid of making the wrong decision? If so, what did you do as a result of 
this fear? 



200 



VIGNETTES 

I AM GOING TO READ TO YOU FOUR STORIES ABOUT PEOPLE AND HOW 
THEY THOUGHT ABOUT THINGS RELATED TO THEIR CANCER 

ID WOULD LIKE YOU TO LISTEN TO THESE STORIES AND WHEN I AM 
FINISHED LET ME KNOW WHICH ONE IS MOST LIKE YOU AND WHICH ONE 
IS LEAST LIKE YOU. 

IF YOU WANT ME TO READ ANY OR ALL OF THEM A SECOND TIME, I'LL BE 
HAPPY TO DO SO. YOU CAN FOLLOW ALONG WITH ME USING THIS CARD 
IF YOU LIKE. 

STORY 1 - JOE (KATHY) 

When Joe (Kathy) was told he had cancer, he had many decisions to make. He had to 
choose how he would get his treatment, he had to decide what to do about his job, and 
how his family would manage while he was tired from treatment. On his way home from 
the doctor's office, he thought, "The doctor knows what he is doing. I'll tell the doctor to 
do whatever treatment he suggests." When he arrived home, he called his boss to discuss 
his job. His boss told him how to handle the times he needed to be out of work. Joe 
(Kathy) felt relieved and put it out of his mind. Within a short time, he simply thought, 
"Well, we'll all manage somehow." and didn't think about it much. Joe (Kathy) is glad he 
decided quickly and feels mostly comfortable with his decision. 

STORY 2 -BILL (SADIE) 

When Bill (Sadie)was told he had cancer, he also had decisions to make. He had to decide 
how his family will be cared for, when he would take treatment, and how they'd manage 
financially. On his way home, thought a lot about what the doctor had said. He discussed 
with his family for many days what the doctor said about his treatment choices. He pretty 
much stayed with what the doctor and medical staff told him and wasn't really interested in 
seeking out additional information on his own. When the Cancer Society offered to send 
information, he accepted but really considered only what the doctor and his nurses told 
him. After thinking for awhile about all the doctor had said, he chose one of the options 
the doctor had given him. It took Bill (SADIE) several weeks to decide all these things. 
He also feels mostly comfortable with his decisions. 



201 



WHICH ONE OF THESE PEOPLE ARE MOST LIKE YOU? WHY? 



WHICH ONE IS LEAST LIKE YOU? WHY? 



STORY 3 - MIKE (JANE) 

When Mike (Jane) was told he had cancer, the decisions he had to make were about 
treatment, supporting his family financially, and how he and his family would cope. On his 
way home, Mike (Jane)gave a lot of thought to what the doctor told him. He also thought 
about where else he would turn for more information. He called the Cancer Society, read 
some pamphlets that were given to him, went to the county library and spoke to an uncle of 
his who had cancer a few years ago. He thought a lot about whether his situation was 
similar to his uncle's. He thought about what kind of person he was and what fit for him. 
It took him a few weeks to gather a lot of information, think long and hard about his life, 
and then make his decisions. Mike (Jane)still thinks about new ideas but feels mostly 
comfortable with his choices. 

STORY 4 - PAUL (PAULA) 

Decisions do not come easy for Paul (Paula), especially important ones. When Paul 
(Paula) was told he had cancer, he remembered precisely what the doctor told him and 
repeated those things over and over again in his mind. He first spoke to his wife about 
what to do about work. Paul (Paula) asked quite a few people about their opinions, 
although he does not accept other people's opinions readily. Paul (Paula) spends a lot of 
time thinking about his options. He likes being very careful about important things and is 
very concerned about making the wrong decision. After thinking almost constantly about 
his options and after going over and over in his mind what the doctor said, Paul (Paula) is 
never really settled on a decision he's comfortable with. He keeps turning over the options 
in his mind. Paul (Paula) is currently taking treatment, but often wonders if he did the right 
thing. 



202 

NEED FOR COGNITION SCALE: Please respond to the following questions 
indicating whether you agree or disagree that the statement is characteristic of you. 

1 . I would prefer complex to simple problems. 

2. I like to have the responsibility of handling a situation that requires a lot of thinking. 

3. Thinking is not my idea of fun.* 

4. 1 would rather do something that requires little thought than something that is sure to 

challenge my thinking abilities.* 
5. 1 try to anticipate and avoid situations where there is likely chance I will have to think in 

depth about something.* 
6. 1 find satisfaction in deliberating hard and for long hours. 

7. I only think as hard as I have to.* 

8. I prefer to think about small, daily projects to long-term ones.* 

9. I like tasks that require little thought once I've learned them.* 

10. The idea of relying on thought to make my way to the top appeals to me. 

1 1. 1 really enjoy a task that involves coming up with new solutions to problems. 
12. Learning new ways to think doesn't excite me very much.* 
13. 1 prefer my life to be filled with puzzles that I must solve. 

14. The notion of thinking abstractly is appealing to me. 

15. I would prefer a task that is intellectual, difficult, and important to one that is somewhat 
important but does not require much thought. 

16. I feel relief rather than satisfaction after completing a task that required a lot of mental 
effort.* 



203 

17. It's enough for me that something gets the job done; I don't care how or why it works.* 

18. I usually end up deliberating about issues even when they do not affect me personally. 



204 



PADUA 

Instructions: The following statements refer to thoughts and behaviors which may occur in 
everyone in everyday life. For each statement, choose the reply which best seems to fit 
you and the degree of disturbance which such thoughts or behaviors may create. Rate 
your replies as follows: 

0= Not at all 

1= a little 

2 = quite a lot 

3 = a lot 

4 = very much 

I. After doing something carefully, I still have the impression I have either done it badly or 
not finished it. 

2. 1 have the impression that I will never be able to explain things clearly, especially when 
talking about important matters. 

3. 1 invent doubts and problems about most of the things I do. 

4. Unpleasant thoughts come into my mind against my will and I cannot get rid of them. 

5. 1 find it difficult to make decisions, even about important matters. 

6. Sometimes I am not sure I have done things which in fact I know I have done. 

7. 1 imagine catastrophic consequences as a result of absent-mindedness or minor error 
which I make. 

8. My brain constantly goes its own way, and I find it difficult to attend to what is 
happening around me. 

9. When I talk, I tend to repeat the same things and the same sentence several times. 

10. In certain situations, I am afraid of losing my self-control and doing embarrassing 
things. 

I I . When I read I have the feeling I have missed something important and must go back 
and reread the passage at least two or three times. 

12. I think or worry at length about having hurt someone without knowing it. 

13. When I start thinking of certain things I become obsessed with them. 






205 



14. When I hear about suicide or crime, I am upset for a long time and find it difficult to 
stop thinking about it. 

15. 1 am sometimes late because I keep doing certain things more often than necessary. 

16. When a thought or doubt comes into my mind, I have to examine it from all points of 
view and cannot stop until 1 have done it. 

17. 1 worry about remembering completely unimportant things and make an effort not to 
forget them. 

1 8. In certain situations, I feel an impulse to eat too much, even if I am ill. 

19. When doubts and worries come to my mind, I cannot rest until I have talked them over 
with a reassuring person. 

20. 1 tend to ask people to repeat the same things to me several times consecutively even 
though I did understand what they said the first time. 

21.1 check and recheck gas and water taps and light switches after turning them off. 

22. I keep on checking forms, documents, checks, etc. in detail to make sure I have filled 
them in correctly. 

23. 1 return home to check doors, windows, drawers, etc. to make sure they are properly 
shut. 

24. 1 keep on going back to see that matches, cigarettes, etc. are properly extinguished. 

25. 1 check letters carefully many times before posting them. 

26. 1 tend to keep on checking things more often than necessary. 

27. When I handle money I count and recount it several times. 

28. Before going to sleep I have to do certain things in a certain order. 

29. Before going to sleep 1 have to do certain things in a certain order. 
30. 1 have to do things several times before I think they are properly done. 

31.1 feel obliged to follow a particular order in dressing, undressing, and washing myself. 



206 



ABILITY TO PROCESS QUESTIONNAIRE 

Please answer the following questions by focusing only on the decision that you just 
identified as the most serious one for you. 

1 . 1 really was able to think about the topic of that decision. 

strongly agree neutral disagree strongly 

agree disagree 

*2. So much was going on in my life at the time of the decision that 1 found it really 
difficult to concentrate. 

strongly agree neutral disagree strongly 

agree disagree 

3. 1 had sufficient time to give that decision careful thought. 

strongly agree neutral disagree strongly 

agree disagree 

*4. My mind was blank during much of the time that I was making that serious decision. 

strongly agree neutral disagree strongly 

agree disagree 

5. My world was free enough of distractions that I was able to really think through that 
decision. 

strongly agree neutral disagree strongly 

agree disagree 

*6. Worries of mine made it very difficult to think carefully about that serious decision. 

strongly agree neutral disagree strongly 

agree disagree 



* These questions are reverse scored. 



207 



ATTITUDE, BELIEF AND EXPERIENCE SURVEY 

Read each of the following statements and decide how much you agree with each 
according to your beliefs and experiences. Please respond according to the following scale. 



1 . Strongly disagree 4. slightly agree 

2. Moderately disagree 5. moderately agree 

3. Slightly disagree 6. strongly agree 



1 I think that having clear rules and order at work is essential for success. 

2. Even after I Ve made up my mind about something, I am always eager to consider a 
different opinion. 

3. I don't like situations that are uncertain. 

4. I dislike questions which could be answered in many different ways. 

5. I like to have friends who are unpredictable. 

6. I find that a well-ordered life with regular hours suits my temperment. 

7. 1 enjoy the uncertainty of going into a new situation without knowing what might 
happen. 

8. When dining out, I like to go to places where I have been before so that I know what to 
expect. 

9. I feel uncomfortable when I don't understand the reason why an event occured in my 
life. 

10. I feel irritated when one person disagrees with what everyone else in a group believes. 

1 1 . I hate to change my plans at the last minute. 

12. I would describe myself as indecisive. 

13. When I go shopping, I have difficulty deciding exactly what it is that 1 want. 



208 

14. When faced with a problem I usually see the one best solution very quickly. 

15. When I am confused about an important issue, I feel very upset. 

16. I tend to put off making important decisions until the last possible moment. 
17. 1 usually make important decisions quickly and confidently. 

1 8. 1 have never been late for an appointment or work. 
19. 1 think it is fun to change my plans at the last moment. 

20. My personal space is usually messy and disorganized. 

2 1 . In most social conflicts, I can easily see which side is right and which is wrong. 

22. I have never known someone that I did not like. 

23. I tend to struggle with most decisions. 

24. I believe that orderliness and organization are among the most important characteristics 
of a good worker. 

25. When considering most conflict situations, I can usually see how both sides could be 
right. 

26. I don't like to be with people who are capable of unexpected actions. 

27. 1 prefer to socialize with familiar friends because I know what to expect from them. 

28. 1 think that I would learn best in a class that lacks clearly stated objectives and 

requirements. 

29. When thinking about a problem, I consider as many different opinions on the issue as 

possible. 

30. 1 don't like to go into a situation without knowing what 1 can expect from it. 

31.1 like to know what people are thinking all the time. 



N 



209 
32. 1 dislike it when a person's statement could mean many different things. 

33. It's annoying to listen to someone who cannot seem to make up his or her mind. 

34. 1 find that establishing a consistent routine enables me to enjoy life more. 

35. I enjoy having a clear and structured mode of life. 

36. I prefer interacting with people who's opinions are very different from my own. 

37. I like to have a place for everything and everything in its place. 

38. I feel uncomfortable when someone's meaning or intention is unclear to me. 

39. I believe that one should never engage in leisure activities. 

40. When trying to solve a problem 1 often see so many possible options that it's confusing. 

41. I always see many possible solutions to problems I face. 

42. I'd rather know bad news than stay in a state of uncertainty. 
43. 1 feel that there is no such thing as an honest mistake. 

44. I do not usually consult many different opinions before forming my own view. 

45. I dislike unpredictable situations. 

46. I have never hurt another person's feelings. 

47. I dislike the routine aspects of my work (studies). 



210 
WAYS OF COPING - CANCER VERSION 

1 . Cancer is generally a difficult or troubling experience for those who have it. The 
following are some possible problems associated with cancer. Please indicate which one 
has been the most difficult or troubling for you in the past six months by circling the 
appropriate number. 

1 Fear and uncertainty about the future due to cancer. 

2 Limitation in physical abilities, appearance, or lifestyle due to cancer. 

3 Pain, symptoms, or discomfort from illness or treatment. 

4 Problems with family or friends related to cancer. 

5 Other (please specify) ___ _____ 

2. How stressful has this problem been for you in the last six months? 

1 Extremely stressful 

2 Stressful 

3 Somewhat stressful 

4 Slightly stressful 

5 Not stressful 

When we experience stress in our lives, we usually try to manage it by trying out different 
ways of thinking or behaving. These can be called ways of coping. Sometimes our 
attempts are successful in helping us solve a problem or feel better and other times they are 
not. The next set of items is on the ways of coping you may have used in trying to manage 
the most stressful part of your cancer. Please read each item below and indicate how often 
you have tried this in the past six months in attempting to cope with the specific problem 
circled above. It is important that you answer every item as best you can. 



How often have you tried this in the past 6 months to manage the problem circled above? 

Does not Rarely Sometimes Often Very 

Apply often 

1. Concentrated on what I had to do next 

the next step ? 12 3 4 

2. Felt that time would make a difference 

the only to do was to wait 12 3 4 

3. Did something which I didn't think would work, 

but at least I was doing something.... 12 3 4 

4. Talked to someone to find out more about the 

situation 12 3 4 

5. Criticized for lectured myself... 12 3 4 



211 



6. Tried nto close off my options, but leave things 
open somewhat 

7. Hoped a miracle would happen.... 

8. Went along with fate; sometimes I just have 

bad luck... 

9. Went on as if nothing were happening 

10. Tried to keep my feelings to myself... 

1 1. Looked for the silver lining, so to speak; tried to 
look on the bright side of things.... 

12. Slept more than usual.... 

13. Looked for sympathy and understanding from 



someone 







14. Was inspired to do something creative... 

15. Tried to forget the whole thing.... 

1 6. Tried to get professional help 

1 7. Changed or grew as a person in a good way. . . 

1 8. Waited to see what would happen before doing 
anything.... 

19. Made a plan of action and followed it.... 

20. Let my feelings out somehow.... 

21. Came out of the experience better than when I 



went in. 







22. Talked to someone who could do something 
concrete about the problem 

23. Tried to make myself feel better by eating, 
drinking, smoking or using drugs. ... 

24. Took a big chance or did something risky. .. . 



2 

2 




4 
4 


2 




4 


2 


3 


4 


2 


3 


4 



4 

4 

4 
4 
4 



4 

4 



212 



25. Tried not to act too hastily or follow my 
first hunch... 

26. Found new faith... 

27. Rediscovered what is important in life.... 

28. Changed something so things would turn 
out all right.. 

29. Avoided being with people in general ... 

30. Didn't let it get to me; refused to think about 
it too much.... 










3 1 . Asked a relative or friend I respect for advice.... 

32. Kept others from knowing how bad things were...O 

33. Made light of the situation; refused to get too 
serious about it 

34. Talked to someone about how I was feeling.... 

35. Took it out on other people 

36. Drew on my past experiences; I was in a similar 
experience before. ... 

37. Knew what had to be done, so redoubled my 
efforts to make things work. ... 



38. Refused to believe it would happen.... 







39. Came up with a couple of different solutions to 
the problem.... 

40. Tried to keep my feelings from interfering with 
other things too much 

4 1 . Changed something about myself. .... 

42. Wished that the situation would go away or 



2 
2 



3 
3 



4 
4 

4 

4 
4 



4 
4 



4 
4 



213 



somehow be over with. 







43. Had fantasies or wishes about how things might 
turn out 

44. Prayed.... 

45. Prepared myself for the worst.... 

46. Went over in my mind what I would say or do 

47. Thought of how a person I admire would handle 
this situation and used that as a model 

48. Reminded myself how much worse things 
could be.. 

49. Tried to find out as much as I could about cancer 
and my own case 



2 
2 
2 
2 



4 
4 
4 

4 



50. Treated the illness as a challenge or battle 
to be won... 







5 1 . Depended mostly on others to handle things or 
tell me what to do 

52. Lived one day at a time or took one step 

at a time.... 



53. Tried something entirely different from any 
of the above. Please describe 



214 



PHYSICIAN ASSESSMENT OF PATIENT PROGNOSIS 

The following patients were interviewed in my study, "Towards a decisional 
processing model for medical decision-making among cancer patients." 

I would greatly appreciate your providing information on the prognosis of the 
following patients of yours according to the scale below. If the stage is not identified 
on this form, please state the stage of illness at initial diagnosis at Shands. 

Prognosis Scale 

Poor=l Fair=2 Gaurded=3 Good= 4 Very Good=5 Excellent 6 



Name Patient number Prognosis Stage 



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BIOGRAPHICAL SKETCH 

At thirteen, I made a commitment to make my life different from 
everything I saw around me. Naturally this commitment was not always fulfilled 
gracefully. The theme of my life has been change. I changed religions, professions, 
marriages, geographic locations, and my name. Perhaps it was my era, coming of age in the 
sixties, or perhaps it was inheriting the "ground-breaking" role of the first child. 

Growing up in the urban metropolis surrounding New York City, 1 had the 
advantages of seeing a world larger than my childhood home. At seventeen, I immersed 
myself in the New York world of fashion and art. It was exciting; it was challenging; it was 
terrifying! 1 sought refuge in what I learned in my traditional childhood home, marriage. 
Two experiences made this marriage worthwhile - becoming a mother and traveling around 
the world. 

When my three sons were babies, I ended my marriage and began my 
education, obtaining my bachelors and masters in counseling psychology from the 
University of North Florida. I aborted my goal to teach in a university and became a 
mental health counselor to support my children. As a single parent in the seventies, my 
daily experience challenged the cultural roles of women. I did not join organizations or 
fight political battles. 1 just lived, supporting my three sons, fighting for credit as a single 
woman, orchestrating child care with limited resources, and confronting those in society 

242 



who chose not to see us as a family. 

My work was rewarding. I provided family therapy and designed prevention 
programs for adolescents. I continued to take institute training aroung the country - 
Bowenian therapy in New York, Gestalt training in Miami, and Relational Theory in 
Boston. I loved all the unanswered questions in my field and longed to pursue them in 
research. 

My new husband invited me to explore my creative abilities again. 
Together we pursued art and writing, culminating in our first published book in 1992 and a 
gallery show. My creativity began to flow into my work as a program developer. I 
designed programs for drug rehabilitation, hospices, and schools. I was involved in film 
production, writing, and speaking engagements. I loved this work because it involved 
change and challenge. 

With my children the absorbed in adolescent pursuits, I had more time to 
devote to my profession and began my own company in 1990, The Mind-Body 
Connection, Inc. For six years, although the company was thriving, I longed for 
intellectual pursuit. One Sunday morning breakfast at Camacho's Cafe in St. Augustine, in 
a four hour conversation with my dearest friend, Vicky and my husband, Ron, 1 discovered 
a way to return to school for my doctorate. 

After three years, I am submitting this document as the culminating 
experience of a life-long dream. I look back with overwhelming appreciation that what was 
once totally unavailable to me in my life is almost in hand and am thankful for the privilege 
of an education. And as I look forward to opening new doors, a certain tension exists 

243 






between my desire to challenge the scientific community with a new concept and to be 
welcomed into the ranks of those I have so long admired. 



244 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy. 




James Archer, Chair 
/Professor of Counselor Education 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy ^^-, 




Martin Heesacker, Cochair 
Professor of Psychology 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy 




Robert Marsh 

Associate Professor of Medicine 



I certify that 1 have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy 




Assistant Professor of Counselor 
Education 



This dissertation was submitted to the Graduate Faculty of the College of Education 
and to the Graduate School and was accepted as partial fulfillment of the requirements for 
the degree of Doctor of Philosophy. 






)ean. College oi/Education 



Dean. Graduate School